Bioactive renal cells for the treatment of chronic kidney disease

ABSTRACT

The present invention concerns methods of using bioactive renal cell populations to provide regenerative effects to a native kidney for the treatment of chronic kidney disease.

FIELD OF THE INVENTION

The present invention relates to methods of treating a subject withchronic kidney disease using bioactive renal cell populations, andmethods of providing regenerative effects to a native kidney usingselected renal cell populations.

BACKGROUND OF THE INVENTION

Chronic kidney disease (CKD) is characterized by progressive nephropathythat, without therapeutic intervention, will worsen; ultimately thepatient may reach end stage renal disease (ESRD). Prevalence data fromthe U.S. to Europe show that approximately 10% of the general populationhave stage 1-3 CKD (ERA, 2009; USRDS, 2011; Jha et al. Chronic kidneydisease: global dimension and perspectives. Lancet. 2013; 382:260-72).Worldwide, the incidence and prevalence of CKD and ESRD are increasingwhile therapeutic outcomes remain poor (Shaw et al. Global estimates ofthe prevalence of diabetes for 2010 and 2030. Diabetes Res Clin Pract.2010; 87:4-14). The greatest cause of ESRD is diabetes mellitus (Postmaand de Zeeuw, 2009), and the incidence of CKD continues to increase,primarily due to the increases in the incidence of type 2 diabetes(Postma and de Zeeuw, 2009). CKD is often accompanied by adverseoutcomes owing to underlying comorbidities and/or risk factors includinghypertension and renovascular disease (Khan et al., 2002; Stenvinkel P.Chronic kidney disease—a public health priority and harbinger ofpremature cardiovascular disease J Intern med. 2010; 268:456-67). Due toserious comorbidities, patients with CKD are 5-11 times more likely tosuffer premature death than survive to progress to ESRD (Collins et al.,2003; Smith et al., 2004). In order to survive, ESRD patients requirerenal replacement therapy (dialysis or transplantation). Preventing ordelaying adverse outcomes of CKD by intervening early-on in the diseaseis the primary strategy in CKD management. Unfortunately, earlytherapeutic approaches to prevent disease progression have not beensuccessful.

As CKD is characterized by low kidney cell proliferation and loss ofregenerative processes (Messier and Leblond. Cell proliferation andmigration as revealed by radiography after injection of thymidine-H3into male rats and mice. Am J Anat. 1960; 106:247-85) maladaptiveresponses and fibrosis lead to progression of CKD. While standard ofcare therapies, such as strict glycemic control and blockade of therenin-angiotensin-aldosterone axis slow progression of diabeticnephropathy, they do not arrest or reverse it. A number of noveltreatment strategies, such as antiproteinuric treatments, inhibitor ofsodium-glucose co-transporter 2, antifibrotic agents, endothelinreceptor antagonists, or transcription factors may slow or arrestprogression of diabetic kidney disease (Quiroga et al. Present andfuture in the treatment of diabetic kidney disease. J Diabetes Res.2015; 2015:801348). In addition, renal cell-based therapy have attractedrecent interest as regeneration of tissues and organs is now within thetechnological reach of modern medicine (Ludlow et al. The Future ofRegenerative Medicine: Urinary System. Tissue Engineering. 2012;18:218-24).

New treatment paradigms involving tissue engineering and cellular-basedapplications have been described that provide substantial and durableaugmentation of kidney functions, slow progression of disease andimprove quality of life in this patient population. Thesenext-generation regenerative medicine technologies provide isolatedrenal cells as a therapeutic option for chronic kidney disease (CKD).Presnell et al. WO/2010/056328 and Ilagan et al. PCT/US2011/036347describe isolated bioactive renal cells, and methods of isolating andculturing the same, as well as methods of treatment with the cellpopulations. Injection of these bioactive renal cells into recipientkidneys has resulted in significant improvement in animal survival andkidney function, as evidenced for example by urine concentration andfiltration functions, in nonclinical studies.

SUMMARY OF THE INVENTION

The invention relates generally to methods of treating CKD patients witha therapeutic composition composed of bioactive renal cells formulatedin a biomaterial that provides stabilization and/or improvement and/orregeneration of kidney function.

In one aspect, the invention concerns a method for the treatment of CKD,wherein the method comprises injecting into the renal cortex of at leastone kidney of a patient having chronic kidney disease a therapeuticallyeffective amount of a composition comprising a bioactive renal cellpopulation (BRC).

In one or more embodiments, the injection is performed using a minimallyinvasive procedure such as percutaneous, laparoscopic or intravascularprocedures. In another embodiment, a guiding cannula insertedpercutaneously is used to puncture the kidney capsule prior to injectionof the composition into the kidney of the patient.

The composition may be administered as a single injection or multipleinjections over a specified time period. In one embodiment, thecomposition is administered with a minimum of one injection in onekidney. In another embodiment, the composition is administered as two ormore injections. The first and second injections may be administered atany time up to 3 months apart, any time up to 6 months apart or atannual intervals. In one embodiment, the second injections isadministered any time up to 3 years after the 1^(st) injection. Thecomposition may also be administered as one, two or more injections inone or both kidneys. In one embodiment, the composition is administeredto subjects who contemporaneously receive standard-of-care treatment forCKD prior to receiving injections of NKA. In another embodiment, the twoor more injections do not result in adverse immunogenic effects. In oneembodiment, the composition is injected into one kidney of the patient.In another embodiment, the composition is injected into both kidneys ofthe patient. In yet another embodiment, single or multiple entry pointsmay be used to inject the composition into the kidney of the patient. Inyet another embodiment, the injection is into the renal parenchyma. Inone embodiment, the patient receives a therapeutic dose at any giveninjection site. In a further embodiment, the patient receives a dose of1-9×10⁶ SRC/g KWest at any given injection site.

In some embodiments, the patient with CKD is further diagnosed as havingtype 2 diabetes mellitus. The underlying cause of the CKD may bediabetic nephropathy in these patients. In one embodiment, the patient'sCKD is defined by an estimated glomerular filtration rate (eGFR) in therange of 15 to 60 mL/min. In another embodiment, the patient with CKDexhibits microalbuminuria may be defined by a urinary albumin-creatinineratio (UACR)≧30 mg/g or urine albumin excretion ≧30 mg/day on 24 hoururine collection.

In all embodiments, the patient's kidney function is improved as aresult of the treatment. In one embodiment, the improved kidney functionis demonstrated by a reduction in the rate of decline or increase inestimated glomerular filtration rate (eGFR). In another embodiment, theimproved kidney function is demonstrated by reduction in total serumcreatinine or the rate of increase in serum creatine (sCr). In one otherembodiment, the improved kidney function is demonstrated by improvedrenal cortical thickness. The improved kidney function may bedemonstrated by structural and functional alterations. In someadditional embodiments, the improved kidney function is demonstrated byimprovement in one or more of the factors in Table 5. In yet anotherembodiment, the improved kidney size and/or structure is determined byrenal imaging. The method of renal imaging may be selected from amongthe technologies including ultrasound, MRI, and renal scintigraphy. Incertain embodiments, the improved renal function is superior to theprior state of kidney structure or function.

In one aspect, the bioactive renal cell population is obtained fromisolation and expansion of renal cells from kidney tissue underculturing conditions that enrich for cells capable of kidneyregeneration. In another embodiment, the bioactive renal cell populationis a selected renal cell (SRC) population obtained after densitygradient separation of the expanded renal cells. In a particularembodiment, the SRC exhibit a buoyant density greater than approximately1.0419 g/mL. In one embodiment, the BRC or SRC contains a greaterpercentage of one or more cell populations and lacks or is deficient inone or more other cell populations, as compared to a starting kidneycell population.

In one embodiment, the BRC or SRC are derived from a native autologousor allogeneic kidney sample. In another embodiment, the BRC or SRC arederived from a non-autologous kidney sample. In one or more of theseembodiments, the sample may be obtained by kidney biopsy.

In another aspect of the invention, the BRC or SRC are formulated in abiomaterial. In one embodiment, the biomaterial comprises agelatin-based hydrogel.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 depicts a simplified flow schedule of the clinical protocol usedin the PHASE I study.

FIG. 2 depicts the estimated glomerular filtration rate pre- andpost-NKA injection of the entire cohort.

FIGS. 3A-3G shows individual changes in the estimated glomerularfiltration rate.

FIG. 4 depicts the estimated glomerular filtration rate pre- andpost-NKA injection of patient #2.

FIG. 5 depicts the rate of decline of renal function pre- and post-NKAinjection with imputed delay in dialysis.

FIG. 6 depicts serum creatinine pre- and post-NKA injection of theentire cohort.

FIGS. 7A-7G shows individual changes in serum creatinine pre- andpost-NKA injection FIG. 8 depicts the study design of the PHASE II,open-label safety and efficacy study.

FIG. 9 depicts patient eGFR data from Phase II Clinical Study RMCL-001.

FIGS. 10A-10B highlight the eGFR increase and stability after 2nd NKAInjection.

FIG. 11 illustrates the reduced rate of eGFR decline.

FIG. 12 illustrates the effect of Advanced Cell Therapy (ACT) on avariety of metabolic measures.

FIG. 13 is a longitudinal renal ultrasound showing a small echogenickidney with difficult longitudinal access approach due to deep positionand axis.

FIG. 14 is a longitudinal renal ultrasound demonstrating trajectory ofouter 18 ga trocar needle (thick) and inner 25 ga injection needle(thin). Circle represent NKA injection.

FIG. 15 shows the transvers renal ultrasound direction of trocar andinner injection needle and approximate trajectory. Circle represent NKAinjection

DETAILED DESCRIPTION OF THE INVENTION

Reference will now be made in detail to certain embodiments of theinvention. While the invention will be described in conjunction with theenumerated embodiments, it will be understood that they are not intendedto limit the invention to those embodiments. On the contrary, theinvention is intended to cover all alternatives, modifications, andequivalents which may be included within the scope of the presentinvention as defined by the claims. One skilled in the art willrecognize many methods and materials similar or equivalent to thosedescribed herein, which could be used in the practice of the presentinvention. The present invention is in no way limited to the methods andmaterials described.

All references cited throughout the disclosure are expresslyincorporated by reference herein in their entirety. In the event thatone or more of the incorporated literature, patents, and similarmaterials differs from or contradicts this application, including butnot limited to defined terms, term usage, described techniques, or thelike, this application controls.

Definitions

Unless defined otherwise, technical and scientific terms used hereinhave the same meaning as commonly understood by one of ordinary skill inthe art to which this invention belongs. Principles of TissueEngineering, 3rd Ed. (Edited by R Lanza, R Langer, & J Vacanti), 2007provides one skilled in the art with a general guide to many of theterms used in the present application. One skilled in the art willrecognize many methods and materials similar or equivalent to thosedescribed herein, which could be used in the practice of the presentinvention. Indeed, the present invention is in no way limited to themethods and materials described.

The words “comprise,” “comprising,” “include,” “including,” and“includes” when used in this specification and claims are intended tospecify the presence of stated features, integers, components, or steps,but they do not preclude the presence or addition of one or more otherfeatures, integers, components, steps, or groups thereof.

The term “cell population” as used herein refers to a number of cellsobtained by isolation directly from a suitable tissue source, usuallyfrom a mammal. For example, a cell population may comprise populationsof kidney cells, and admixtures thereof. The isolated cell populationmay be subsequently cultured in vitro. Those of ordinary skill in theart will appreciate that various methods for isolating and culturingcell populations for use with the present invention and various numbersof cells in a cell population that are suitable for use in the presentinvention. A cell population may be an unfractionated, heterogeneouscell population or an enriched homogeneous cell population derived froman organ or tissue, e.g., the kidney. For example, a heterogeneous cellpopulation may be isolated from a tissue biopsy or from whole organtissue. Alternatively, the heterogeneous cell population may be derivedfrom in vitro cultures of mammalian cells, established from tissuebiopsies or whole organ tissue. An unfractionated heterogeneous cellpopulation may also be referred to as a non-enriched cell population. Inone embodiment, the cell populations contain bioactive cells. Homogenouscell populations comprise a greater proportion of cells of the same celltype, sharing a common phenotype, or having similar physical properties,as compared to an unfractionated, heterogeneous cell population. Forexample, a homogeneous cell population may be isolated, extracted, orenriched from heterogeneous kidney cell population. In one embodiment, ahomogeneous cell population is obtained as a cell fraction using densitygradient separation of a heterogeneous cell suspension.

As used herein, the term “bioactive” means “possessing biologicalactivity,” such as a pharmacological or a therapeutic activity. In oneembodiment, the bioactivity is enhancement of renal function and/oreffect on renal homeostasis. In certain embodiments, the biologicalactivity is, without limitation, analgesic; antiviral;anti-inflammatory; antineoplastic; immune stimulating; immunemodulating; enhancement of cell viability, antioxidation, oxygencarrier, cell recruitment, cell attachment, immunosuppressant,angiogenesis, wound healing activity, or any combination thereof.

The term “bioactive renal cells” or “BRC” as used herein refers to renalcells having one or more of the following properties: capability toenhance renal functions, capability to affect (improve) renalhomeostasis, and capability to promote healing, repair and/orregeneration of renal tissue or kidney. These cells may includefunctional tubular cells (based on improvements in creatinine excretionand protein retention), glomerular cells (based on improvement inprotein retention), vascular cells and other cells of thecorticomedullary junction. Bioactive renal cells (BRC) are obtained fromisolation and expansion of renal cells from kidney tissue using methodsthat select for bioactive cells. In one embodiment, the bioactive renalcells have a regenerative effect on the kidney.

The term “selected renal cells” or “SRC” as used herein refers to cellsobtained from isolation and expansion of bioactive renal cells (ashereinabove defined) from a suitable renal tissue source, wherein theSRC contains a greater percentage of one or more cell populations andlacks or is deficient in one or more other cell populations, as comparedto a starting kidney cell population. SRCs are isolated populations ofkidney cells, or admixtures thereof, enriched for specific bioactivecomponents or cell types and/or depleted of specific inactive orundesired components or cell types for use in the treatment of kidneydisease, i.e., providing stabilization and/or improvement and/orregeneration of kidney function. SRCs provide superior therapeutic andregenerative outcomes as compared with the starting population. In oneembodiment, SRCs are obtained from the patient's renal cortical tissuevia a kidney biopsy and selected by density gradient separation of theexpanded renal cells. SRCs are composed primarily of renal tubularcells. Other parenchymal (vascular) and stromal (collecting duct) cellsmay be sparsely present in the isolated preparation. In one embodiment,the selected renal cells (SRCs) have a regenerative effect on thekidney.

The term “native organ” shall mean the organ of a living subject. Thesubject may be healthy or unhealthy. An unhealthy subject may have adisease associated with that particular organ.

The term “native kidney” shall mean the kidney of a living subject. Thesubject may be healthy or unhealthy. An unhealthy subject may have akidney disease.

The term “regenerative effect” shall mean an effect which provides abenefit to a native organ, such as the kidney. The effect may include,without limitation, a reduction in the degree of injury to a nativeorgan or an improvement in, restoration of, or stabilization of a nativeorgan function or structure. Renal injury may be in the form offibrosis, inflammation, glomerular hypertrophy, atrophy, etc. andrelated to a disease associated with the native organ in the subject.

The term “admixture” as used herein in the context of a cell populationrefers to a combination of two or more isolated, enriched cellpopulation phenotypes derived from an unfractionated, heterogeneous cellpopulation. According to certain embodiments, the cell populations ofthe present invention are renal cell populations.

An “enriched” cell population or preparation refers to a cell populationderived from a starting organ cell population (e.g., an unfractionated,heterogeneous cell population) that contains a greater percentage of aspecific cell type than the percentage of that cell type in the startingpopulation. For example, a starting kidney cell population can beenriched for a first, a second, a third, a fourth, a fifth, and so on,cell population of interest. As used herein, the terms “cellpopulation”, “cell preparation” and “cell phenotype” are usedinterchangeably.

The term “hypoxic” culture conditions as used herein refers to cultureconditions in which cells are subjected to a reduction in availableoxygen levels in the culture system relative to standard cultureconditions in which cells are cultured at atmospheric oxygen levels(about 21%). Non-hypoxic conditions are referred to herein as normal ornormoxic culture conditions.

The term “oxygen-tunable” as used herein refers to the ability of cellsto modulate gene expression (up or down) based on the amount of oxygenavailable to the cells. “Hypoxia-inducible” refers to the upregulationof gene expression in response to a reduction in oxygen tension(regardless of the pre-induction or starting oxygen tension).

The term “biomaterial” as used herein refers to a natural or syntheticbiocompatible material that is suitable for introduction into livingtissue supporting the selected bioactive cells in a viable state. Anatural biomaterial is a material that is made by or originates from aliving system. Synthetic biomaterials are materials which are not madeby or do not originate from a living system. The biomaterials disclosedherein may be a combination of natural and synthetic biocompatiblematerials. As used herein, biomaterials include, for example, polymericmatrices and scaffolds. Those of ordinary skill in the art willappreciate that the biomaterial(s) may be configured in various forms,for example, as porous foam, gels, liquids, beads, solids, and maycomprise one or more natural or synthetic biocompatible materials. Inone embodiment, the biomaterial is the liquid form of a solution that iscapable of becoming a hydrogel.

The term “kidney disease” as used herein refers to disorders associatedwith any stage or degree of acute or chronic renal failure that resultsin a loss of the kidney's ability to perform the function of bloodfiltration and elimination of excess fluid, electrolytes, and wastesfrom the blood. Kidney disease also includes endocrine dysfunctions suchas anemia (erythropoietin-deficiency), and mineral imbalance (Vitamin Ddeficiency). Kidney disease may originate in the kidney or may besecondary to a variety of conditions, including (but not limited to)heart failure, hypertension, diabetes, autoimmune disease, or liverdisease. Kidney disease may be a condition of chronic renal failure thatdevelops after an acute injury to the kidney. For example, injury to thekidney by ischemia and/or exposure to toxicants may cause acute renalfailure; incomplete recovery after acute kidney injury may lead to thedevelopment of chronic renal failure.

The term “treatment” refers to both therapeutic treatment andprophylactic or preventative measures for kidney disease, anemia,tubular transport deficiency, or glomerular filtration deficiencywherein the object is to reverse, prevent or slow down (lessen) thetargeted disorder. Those in need of treatment include those alreadyhaving a kidney disease, anemia, tubular transport deficiency, orglomerular filtration deficiency as well as those prone to having akidney disease, anemia, tubular transport deficiency, or glomerularfiltration deficiency or those in whom the kidney disease, anemia,tubular transport deficiency, or glomerular filtration deficiency is tobe prevented. The term “treatment” as used herein includes thestabilization and/or improvement of kidney function.

The term “in vivo contacting” as used herein refers to direct contact invivo between products secreted by an enriched population of cells and anative organ. For example, products secreted by an enriched populationof renal cells (or an admixture or construct containing renalcells/renal cell fractions) may in vivo contact a native kidney. Thedirect in vivo contacting may be paracrine, endocrine, or juxtacrine innature. The products secreted may be a heterogeneous population ofdifferent products described herein.

The terms “construct” or “formulation” refer to one or more cellpopulations deposited on or in a surface of a scaffold or matrix made upof one or more synthetic or naturally-occurring biocompatible materials.The one or more cell populations may be coated with, deposited on,embedded in, attached to, seeded, or entrapped in a biomaterial made upof one or more synthetic or naturally-occurring biocompatiblebiomaterials, polymers, proteins, or peptides. The one or more cellpopulations may be combined with a biomaterial or scaffold or matrix invitro or in vivo. The one or more biomaterials used to generate theconstruct or formulation may be selected to direct, facilitate, orpermit dispersion and/or integration of the cellular components of theconstruct with the endogenous host tissue, or to direct, facilitate, orpermit the survival, engraftment, tolerance, or functional performanceof the cellular components of the construct or formulation.

The term “Neo-Kidney Augment (NKA)” refers to a bioactive cellformulation which is an injectable product composed of autologous,homologous selected renal cells (SRC) formulated in a biomaterialcomprised of a gelatin-based hydrogel. The term “Advance Cell Therapy(ACT)” refers to treatment with NKA.

The term “subject” shall mean any single human subject, including apatient, eligible for treatment, who is experiencing or has experiencedone or more signs, symptoms, or other indicators of a kidney disease.Such subjects include without limitation subjects who are newlydiagnosed or previously diagnosed and are now experiencing a recurrenceor relapse, or are at risk for a kidney disease, no matter the cause.The subject may have been previously treated for a kidney disease, ornot so treated.

The term “patient” refers to any single animal, more preferably a mammal(including such non-human animals as, for example, dogs, cats, horses,rabbits, zoo animals, cows, pigs, sheep, and non-human primates) forwhich treatment is desired. Most preferably, the patient herein is ahuman.

The term “sample” or “patient sample” or “biological sample” shallgenerally mean any biological sample obtained from a subject or patient,body fluid, body tissue, cell line, tissue culture, or other source. Theterm includes tissue biopsies such as, for example, kidney biopsies. Theterm includes cultured cells such as, for example, cultured mammaliankidney cells. Methods for obtaining tissue biopsies and cultured cellsfrom mammals are well known in the art. If the term “sample” is usedalone, it shall still mean that the “sample” is a “biological sample” or“patient sample”, i.e., the terms are used interchangeably.

The term “test sample” refers to a sample from a subject that has beentreated by a method of the present invention. The test sample mayoriginate from various sources in the mammalian subject including,without limitation, blood, semen, serum, urine, bone marrow, mucosa,tissue, etc.

The term “control” or “control sample” refers a negative or positivecontrol in which a negative or positive result is expected to helpcorrelate a result in the test sample. Controls that are suitable forthe present invention include, without limitation, a sample known toexhibit indicators characteristic of normal kidney function, a sampleobtained from a subject known not to have kidney disease, and a sampleobtained from a subject known to have kidney disease. In addition, thecontrol may be a sample obtained from a subject prior to being treatedby a method of the present invention. An additional suitable control maybe a test sample obtained from a subject known to have any type or stageof kidney disease, and a sample from a subject known not to have anytype or stage of kidney disease. A control may be a normal healthymatched control. Those of skill in the art will appreciate othercontrols suitable for use in the present invention.

“Regeneration prognosis”, “regenerative prognosis”, or “prognostic forregeneration” generally refers to a forecast or prediction of theprobable regenerative course or outcome of the administration orimplantation of a cell population, admixture or construct describedherein. For a regeneration prognosis, the forecast or prediction may beinformed by one or more of the following: improvement of a functionalorgan (e.g., the kidney) after implantation or administration,development of a functional kidney after implantation or administration,development of improved kidney function or capacity after implantationor administration, and expression of certain markers by the nativekidney following implantation or administration.

“Regenerated organ” refers to a native organ after implantation oradministration of a cell population, admixture, or construct asdescribed herein. The regenerated organ is characterized by variousindicators including, without limitation, development of function orcapacity in the native organ, improvement of function or capacity in thenative organ, and the expression of certain markers in the native organ.Those of ordinary skill in the art will appreciate that other indicatorsmay be suitable for characterizing a regenerated organ.

“Regenerated kidney” refers to a native kidney after implantation oradministration of a cell population, admixture, or construct asdescribed herein. The regenerated kidney is characterized by variousindicators including, without limitation, development of function orcapacity in the native kidney, improvement of function or capacity inthe native kidney, and the expression of certain markers in the nativekidney. Those of ordinary skill in the art will appreciate that otherindicators may be suitable for characterizing a regenerated kidney.

The term “hydrogel” is used herein to refer to a substance formed whenan organic polymer (natural or synthetic) is cross-linked via covalent,ionic, or hydrogen bonds to create a three-dimensional open-latticestructure which entraps water molecules to form a gel. Examples ofmaterials which can be used to form a hydrogel include polysaccharidessuch as alginate, polyphosphazines, and polyacrylates, which arecrosslinked tonically, or block copolymers such as Pluronics™ orTetronics™, polyethylene oxide-polypropylene glycol block copolymerswhich are crosslinked by temperature or pH, respectively. The hydrogelused herein is preferably a biodegradable gelatin-based hydrogel.

An “adverse event” is any unfavorable and unintended sign, symptom, ordisease temporally associated with the use of an investigational(medicinal) product or other protocol-imposed intervention, regardlessof attribution; and includes: AEs not previously observed in the patientthat emerge during the protocol-specified AE reporting period, includingsigns or symptoms associated with chronic kidney disease that were notpresent before the AE reporting period; complications that occur as aresult of protocol-mandated interventions (e.g., invasive proceduressuch as biopsies); or preexisting medical conditions (other than thecondition being studied) judged by the investigator to have worsened inseverity or frequency or changed in character during theprotocol-specified AE reporting period.

An adverse event is classified as a “Serious Adverse Events” (SAE) if itmeets the following criteria: results in death (i.e., the AE actuallycauses or leads to death); life threatening (i.e., the AE, in the viewof the investigator, places the patient at immediate risk of death, butnot including an AE that, had it occurred in a more severe form, mighthave caused death); requires or prolongs inpatient hospitalization;results in persistent or significant disability/incapacity (i.e., the AEresults in substantial disruption of the patient's ability to conductnormal life functions); results in a congenital anomaly/birth defect ina neonate/infant born to a mother exposed to the investigationalproduct; or is considered a significant medical event by theinvestigator based on medical judgment (e.g., may jeopardize the patientor may require medical/surgical intervention to prevent one of theoutcomes listed above). All AEs that do not meet any of the criteria forserious are regarded as non-serious AEs. The terms “severe” and“serious” are not synonymous. Severity (or intensity) refers to thegrade of a specific AE, e.g., mild (Grade 1), moderate (Grade 2), orsevere (Grade 3) myocardial infarction. “Serious” is a regulatorydefinition (see previous definition) and is based on patient or eventoutcome or action criteria usually associated with events that pose athreat to a patient's life or functioning. Seriousness (not severity)serves as the guide for defining regulatory reporting obligations fromthe Sponsor to applicable regulatory authorities. Severity andseriousness should be independently assessed when recording AEs and SAEson the eCRF

Cell Populations

As described above, BRCs are an isolated population of regenerativerenal cells naturally involved in renal repair and regeneration. In oneembodiment, BRCs are obtained from renal cells isolated from kidneytissue by enzymatic digestion and expanded using standard cell culturetechniques. In one embodiment, the cell culture medium is designed toexpand bioactive renal cells with regenerative capacity. In one otherembodiment, the cell culture medium does not contain any differentiationfactors. In another embodiment, the expanded heterogeneous mixtures ofrenal cells are cultured in hypoxic conditions to further enrich thecomposition of cells with regenerative capacity. Without wishing to bebound by theory, this may be due to one or more of the followingphenomena: 1) selective survival, death, or proliferation of specificcellular components during the hypoxic culture period; 2) alterations incell granularity and/or size in response to the hypoxic culture, therebyeffecting alterations in buoyant density and subsequent localizationduring density gradient separation; and 3) alterations in cellgene/protein expression in response to the hypoxic culture period,thereby resulting in differential characteristics of the cells withinthe isolated and expanded population.

The expanded bioactive renal cells may be further subjected to densitygradient separation to obtain the SRC. Specifically, density gradientcentrifugation is used to separate harvested renal cell populationsbased on cell buoyant density. In one embodiment, the SRC are generatedby using, in part, the OPTIPREP (Axis-Shield) density gradient medium,comprising 60% nonionic iodinated compound iodixanol in water. One ofskill in the art, however, will recognize that any density gradient orother means, e.g., immunological separation using cell surface markersknown in the art, comprising necessary features for isolating the cellpopulations of the instant invention may be used in accordance with theinvention. In one embodiment, the cellular fraction exhibiting buoyantdensity greater than approximately 1.0419 g/mL is collected aftercentrifugation as a distinct pellet. In another embodiment, cellsmaintaining a buoyant density of less than 1.0419 g/mL are excluded anddiscarded.

The therapeutic compositions, and formulations thereof, of the presentinvention may contain isolated, heterogeneous populations of kidneycells, and admixtures thereof, enriched for specific bioactivecomponents or cell types and/or depleted of specific inactive orundesired components or cell types for use in the treatment of kidneydisease, i.e., providing stabilization and/or improvement and/orregeneration of kidney function and/or structure, were previouslydescribed in Presnell et al. U.S. 2011-0117162 and Ilagan et al.PCT/US2011/036347, the entire contents of which are incorporated hereinby reference. The compositions may contain isolated renal cell fractionsthat lack cellular components as compared to a healthy individual yetretain therapeutic properties, i.e., provide stabilization and/orimprovement and/or regeneration of kidney function. The cellpopulations, cell fractions, and/or admixtures of cells described hereinmay be derived from healthy individuals, individuals with a kidneydisease, or subjects as described herein.

The present invention contemplates therapeutic compositions of selectedrenal cell populations that are to be administered to target organs ortissue in a subject in need. A bioactive selected renal cell populationgenerally refers to a cell population potentially having therapeuticproperties upon administration to a subject. For example, uponadministration to a subject in need, a bioactive renal cell populationcan provide stabilization and/or improvement and/or repair and/orregeneration of kidney function in the subject. The therapeuticproperties may include a repair or regenerative effect.

In one embodiment, the source of cells is the same as the intendedtarget organ or tissue. For example, BRCs and/or SRCs may be sourcedfrom the kidney to be used in a formulation to be administered to thekidney. In one embodiment, the cell populations are derived from akidney biopsy. In another embodiment, the cell populations are derivedfrom whole kidney tissue. In one other embodiment, the cell populationsare derived from in vitro cultures of mammalian kidney cells,established from kidney biopsies or whole kidney tissue. In certainembodiments, the BRCs and/or SRCs comprise heterogeneous mixtures orfractions of bioactive renal cells. The BRCs and/or SRCs may be derivedfrom or are themselves renal cell fractions from healthy individuals. Inaddition, the present invention provides renal cell fractions obtainedfrom an unhealthy individual that may lack certain cellular componentswhen compared to the corresponding renal cell fractions of a healthyindividual, yet still retain therapeutic properties. The presentinvention also provides therapeutically-active cell populations lackingcellular components compared to a healthy individual, which cellpopulations can be, in one embodiment, isolated and expanded fromautologous sources in various disease states.

In one embodiment, the SRCs are obtained from isolation and expansion ofrenal cells from a patient's renal cortical tissue via a kidney biopsy.Renal cells are isolated from the kidney tissue by enzymatic digestion,expanded using standard cell culture techniques, and selected by densitygradient centrifugation from the expanded renal cells. In thisembodiment, SRC are composed primarily of renal epithelial cells whichare known for their regenerative potential. Other parenchymal (vascular)and stromal cells may be sparsely present in the autologous SRCpopulation.

As described herein, the present invention is based, in part, on thesurprising finding that certain subfractions of a heterogeneouspopulation of renal cells, enriched for bioactive components anddepleted of inactive or undesired components, provide superiortherapeutic and regenerative outcomes than the starting population.

Renal cell isolation and expansion provides a mixture of renal celltypes including renal epithelial cells and stromal cells. As notedabove, SRC are obtained by density gradient separation of the expandedrenal cells. The primary cell type in the density gradient separated SRCpopulation is of tubular epithelial phenotype. The characteristics ofSRC obtained from expanded renal cells is evaluated using multi-prongedapproach. Cell morphology, growth kinetics and cell viability aremonitored during the renal cell expansion process. SRC buoyant densityand viability is characterized by density gradient and Trypan Blueexclusion. SRC phenotype is characterized by flow cytometry and SRCfunction is demonstrated by expression of VEGF and KIM-1. Cell functionof SRC, pre-formulation, can also be evaluated by measuring the activityof two specific enzymes; GGT (γ-glutamyl transpeptidase) and LAP(leucine aminopeptidase), found in kidney proximal tubules.

Although selected renal cell compositions are described herein, thepresent invention contemplates compositions containing a variety ofother active agents. Other suitable active agents include, withoutlimitation, cellular aggregates, acellular biomaterials, secretedproducts from bioactive cells, large and small molecule therapeutics, aswell as combinations thereof. For example, one type of bioactive cellsmay be combined with biomaterial-based microcarriers with or withouttherapeutic molecules or another type of bioactive cells, unattachedcells may be combined with acellular particles.

Biomaterials

A variety of biomaterials may be combined with an active agent toprovide the therapeutic formulations of the present invention. Thebiomaterials may be in any suitable shape (e.g., beads) or form (e.g.,liquid, gel, etc.). Suitable biomaterials in the form of polymericmatrices are described in Bertram et al. U.S. Published Application20070276507 (incorporated herein by reference in its entirety). In oneembodiment, the polymeric matrix may be a biocompatible material formedfrom a variety of synthetic or naturally-occurring materials including,but not limited to, open-cell polylactic acid (OPLA®), cellulose ether,cellulose, cellulosic ester, fluorinated polyethylene, phenolic,poly-4-methylpentene, polyacrylonitrile, polyamide, polyamideimide,polyacrylate, polybenzoxazole, polycarbonate, polycyanoarylether,polyester, polyestercarbonate, polyether, polyetheretherketone,polyetherimide, polyetherketone, polyethersulfone, polyethylene,polyfluoroolefin, polyimide, polyolefin, polyoxadiazole, polyphenyleneoxide, polyphenylene sulfide, polypropylene, polystyrene, polysulfide,polysulfone, polytetrafluoroethylene, polythioether, polytriazole,polyurethane, polyvinyl, polyvinylidene fluoride, regenerated cellulose,silicone, urea-formaldehyde, collagens, gelatin, alginate, laminins,fibronectin, silk, elastin, alginate, hyaluronic acid, agarose, orcopolymers or physical blends thereof. In a preferred embodiment, thebiomaterial is a hydrogel.

Hydrogels may be formed from a variety of polymeric materials and areuseful in a variety of biomedical applications. Hydrogels can bedescribed physically as three-dimensional networks of hydrophilicpolymers. Depending on the type of hydrogel, they contain varyingpercentages of water, but altogether do not dissolve in water. Despitetheir high water content, hydrogels are capable of additionally bindinggreat volumes of liquid due to the presence of hydrophilic residues.Hydrogels swell extensively without changing their gelatinous structure.The basic physical features of hydrogel can be specifically modified,according to the properties of the polymers used and the additionalspecial equipments of the products.

The hydrogel material preferably does not induce an inflammatoryresponse. Examples of other materials which can be used to form ahydrogel include (a) modified alginates, (b) polysaccharides (e.g.gellan gum and carrageenans) which gel by exposure to monovalentcations, (c) polysaccharides (e.g., hyaluronic acid) that are veryviscous liquids or are thixotropic and form a gel over time by the slowevolution of structure, (d) gelatin or collagen, and (e) polymerichydrogel precursors (e.g., polyethylene oxide-polypropylene glycol blockcopolymers and proteins). U.S. Pat. No. 6,224,893 B1 provides a detaileddescription of the various polymers, and the chemical properties of suchpolymers, that are suitable for making hydrogels in accordance with thepresent invention.

In a particular embodiment, the hydrogel used to formulate thebiomaterials of the present invention is gelatin-based. Gelatin is anon-toxic, biodegradable and water-soluble protein derived fromcollagen, which is a major component of mesenchymal tissue extracellularmatrix (ECM). Gelatin retains informational signals including anarginine-glycine-aspartic acid (RGD) sequence, which promotes celladhesion, proliferation and stem cell differentiation. A characteristicproperty of gelatin is that it exhibits Upper Critical SolutionTemperature behavior (UCST). Above a specific temperature threshold of40° C., gelatin can be dissolved in water by the formation of flexible,random single coils. Upon cooling, hydrogen bonding and Van der Waalsinteractions occur, resulting in the formation of triple helices. Thesecollagen-like triple helices act as junction zones and thus trigger thesol-gel transition. Gelatin is widely used in pharmaceutical and medicalapplications.

The biomaterials described herein may also be designed or adapted torespond to certain external conditions, e.g., in vitro or in vivo. Inone embodiment, the biomaterials are temperature-sensitive (e.g., eitherin vitro or in vivo). In another embodiment, the biomaterials areadapted to respond to exposure to enzymatic degradation (e.g., either invitro or in vivo). The biomaterials' response to external conditions canbe fine-tuned as described herein. Temperature sensitivity of theformulation described can be varied by adjusting the percentage of abiomaterial in the formulation. For example, the percentage of gelatinin a solution can be adjusted to modulate the temperature sensitivity ofthe gelatin in the final formulation (e.g., liquid, gel, beads, etc.).In one embodiment, the gelatin solution may be provided in PBS, DMEM, oranother suitable solvent. Alternatively, biomaterials may be chemicallycross-linked to provide greater resistance to enzymatic degradation. Forinstance, a carbodiimide crosslinker may be used to chemically crosslinkgelatin beads thereby providing a reduced susceptibility to endogenousenzymes.

In one aspect, the formulations described herein incorporatebiomaterials having properties which create a favorable environment forthe active agent, such as bioactive renal cells, to be administered to asubject. In one embodiment, the formulation contains a first biomaterialthat provides a favorable environment from the time the active agent isformulated with the biomaterial up until the point of administration tothe subject. In one other embodiment, the favorable environment concernsthe advantages of having bioactive cells suspended in a substantiallysolid state versus cells in a fluid (as described herein) prior toadministration to a subject. In another embodiment, the firstbiomaterial is a temperature-sensitive biomaterial. Thetemperature-sensitive biomaterial may have (i) a substantially solidstate at about 8° C. or below, and (ii) a substantially liquid state atambient temperature or above. In one embodiment, the ambient temperatureis about room temperature. The cell populations and preparationsdescribed herein may be coated with, deposited on, embedded in, attachedto, seeded, suspended in, or entrapped in a temperature-sensitivebiomaterial.

In another aspect, the present invention provides formulations thatcontain biomaterials which degrade over a period time on the order ofminutes, hours, or days. This is in contrast to a large body or workfocusing on the implantation of solid materials that then slowly degradeover days, weeks, or months. In one embodiment, the biomaterial has oneor more of the following characteristics: biocompatibility,biodegradeable/bioresorbable, a substantially solid state prior to andduring implantation into a subject, loss of structural integrity(substantially solid state) after implantation, and cytocompatibleenvironment to support cellular viability. The biomaterial's ability tokeep implanted particles spaced out during implantation enhances nativetissue ingrowth. The biomaterial also facilitates implantation of solidformulations. The biomaterial provides for localization of theformulation described herein since inserted of a solid unit helpsprevent the delivered materials from dispersing within the tissue duringimplantation. For cell-based formulations, a solid biomaterial alsoimproves stability and viability of anchorage dependent cells comparedto cells suspended in a fluid. However, the short duration of thestructural integrity means that soon after implantation, the biomaterialdoes not provide a significant barrier to tissue ingrowth or integrationof the delivered cells/materials with host tissue.

Bioactive Cell Formulations

The bioactive cell formulations described herein contain implantableconstructs made from the above-referenced biomaterials having thebioactive renal cells described herein for the treatment of kidneydisease in a subject in need. In one embodiment, the construct is madeup of a biocompatible material or biomaterial, scaffold or matrixcomposed of one or more synthetic or naturally-occurring biocompatiblematerials and one or more cell populations or admixtures of cellsdescribed herein deposited on or embedded in a surface of the scaffoldby attachment and/or entrapment. In certain embodiments, the constructis made up of a biomaterial and one or more cell populations oradmixtures of cells described herein coated with, deposited on,deposited in, attached to, entrapped in, embedded in, seeded, orcombined with the biomaterial component(s). Any of the cell populationsdescribed herein, including enriched cell populations or admixturesthereof, may be used in combination with a matrix to form a construct.In one embodiment, the bioactive cell formulation is made up of abiocompatible material or biomaterial and an SRC population describedherein.

In one embodiment, the bioactive cell formulation is a Neo-KidneyAugment (NKA), which is an injectable product composed of autologous,homologous selected renal cells (SRC) formulated in a Biomaterial(gelatin-based hydrogel). In one aspect, autologous, homologous SRC areobtained from isolation and expansion of renal cells from the patient'srenal cortical tissue via a kidney biopsy and selection by densitygradient centrifugation from the expanded renal cells. SRC are composedprimarily of renal epithelial cells which are well known for theirregenerative potential (Humphreys et al. (2008) Intrinsic epithelialcells repair the kidney after injury. Cell Stem Cell. 2(3):284-91).Injection of SRC into recipient kidneys has resulted in significantimprovement in animal survival, urine concentration and filtrationfunctions in nonclinical studies. However, SRC have limited shelf lifeand stability. Formulation of SRC in a gelatin-based hydrogelbiomaterial provides enhanced stability of the cells thus extendingproduct shelf life, improved stability of NKA during transport anddelivery of NKA into the kidney cortex for clinical utility.

In another aspect, NKA is manufactured by first obtaining renal corticaltissue from the donor/recipient using a standard-of-clinical-care kidneybiopsy procedure. Renal cells are isolated from the kidney tissue byenzymatic digestion and expanded using standard cell culture techniques.Cell culture medium is designed to expand primary renal cells and doesnot contain any differentiation factors. Harvested renal cells aresubjected to density gradient separation to obtain SRC.

One aspect of the invention further provides a formulation made up ofbiomaterials designed or adapted to respond to external conditions asdescribed herein. As a result, the nature of the association of thebioactive cell population with the biomaterial in a construct willchange depending upon the external conditions. For example, a cellpopulation's association with a temperature-sensitive biomaterial varieswith temperature. In one embodiment, the construct contains a bioactiverenal cell population and biomaterial having a substantially solid stateat about 8° C. or lower and a substantially liquid state at aboutambient temperature or above, wherein the cell population is suspendedin the biomaterial at about 8° C. or lower.

However, the cell population is substantially free to move throughoutthe volume of the biomaterial at about ambient temperature or above.Having the cell population suspended in the substantially solid phase ata lower temperature provides stability advantages for the cells, such asfor anchorage-dependent cells, as compared to cells in a fluid.Moreover, having cells suspended in the substantially solid stateprovides one or more of the following benefits: i) prevents settling ofthe cells, ii) allows the cells to remain anchored to the biomaterial ina suspended state; iii) allows the cells to remain more uniformlydispersed throughout the volume of the biomaterial; iv) prevents theformation of cell aggregates; and v) provides better protection for thecells during storage and transportation of the formulation. Aformulation that can retain such features leading up to theadministration to a subject is advantageous at least because the overallhealth of the cells in the formulation will be better and a more uniformand consistent dosage of cells will be administered.

In certain embodiments, the manufacturing process for the bioactive cellformulations is designed to deliver a product in approximately fourweeks from patient biopsy to product implant. Inherentpatient-to-patient tissue variability poses a challenge to deliverproduct on a fixed implant schedule. Expanded renal cells are routinelycryopreserved during cell expansion to accommodate for thispatient-dependent variation in cell expansion. Cryopreserved renal cellsprovide a continuing source of cells in the event that another treatmentis needed (e.g., delay due to patient sickness, unforeseen processevents, etc.) and to manufacture multiple doses for re-implantation, asrequired.

For embodiments where the bioactive cell formulation is composed ofautologous, homologous cells formulated in a biomaterial (gelatin-basedhydrogel), the final composition may be about 20×10⁶ cells per mL toabout 200×10⁶ cells per mL in a gelatin solution with Dulbecco'sPhosphate Buffered Saline (DPBS). In some embodiments, the number ofcells per mL of product is about 20×10⁶ cells per mL, about 40×10⁶ cellsper mL, about 60×10⁶ cells per mL, about 100×10⁶ cells per mL, about120×10⁶ cells per mL, about 140×10⁶ cells per mL, about 160×10⁶ cellsper mL, about 180×10⁶ cells per mL, or about 200×10⁶ cells per mL. Insome embodiments, the gelatin is present at about 0.5%, about 0.55%,about 0.6%, about 0.65%, about 0.7%, about 0.75%, about 0.8%, about0.85%, about 0.9%, about 0.95% or about 1%, (w/v) in the solution. Inone example, the biomaterial is a 0.88% (w/v) gelatin solution in DPBS.

In a preferred embodiment, NKA is presented in a sterile, single-use 10mL syringe. The final volume is calculated from the concentration of100×10⁶ SRC/mL of NKA and the target dose of 3.0×10⁶ SRC/g kidney weight(estimated by MRI). Therapeutic dosage may also be determined by thesurgeon at the time of injection based on the patient's kidney weight.

A total number of cells may be selected for the formulation and thevolume of the formulation may be adjusted to reach the propertherapeutic dosage. In some embodiments, the formulation may contain adosage of cells to a subject that is a single dosage or a single dosageplus additional dosages. In other embodiments, the dosages may beprovided by way of a construct as described herein. The therapeuticallyeffective amount of the bioactive renal cell populations or admixturesof renal cell populations described herein can range from the maximumnumber of cells that is safely received by the subject to the minimumnumber of cells necessary for treatment of kidney disease, e.g.,stabilization, reduced rate-of-decline, or improvement of one or morekidney functions.

The therapeutically effective amount of the bioactive renal cellpopulations or admixtures thereof described herein can also be suspendedin a pharmaceutically acceptable carrier or excipient. Such a carrierincludes, but is not limited to basal culture medium plus 1% serumalbumin, saline, buffered saline, dextrose, water, collagen, alginate,hyaluronic acid, fibrin glue, polyethyleneglycol, polyvinylalcohol,carboxymethylcellulose and combinations thereof. The formulation shouldsuit the mode of administration.

The bioactive renal cell preparation(s), or admixtures thereof, orcompositions are formulated in accordance with routine procedures as apharmaceutical composition adapted for administration to human beings.Typically, compositions for intravenous administration, intra-arterialadministration or administration within the kidney capsule, for example,are solutions in sterile isotonic aqueous buffer. Where necessary, thecomposition can also include a local anesthetic to ameliorate any painat the site of the injection. Generally, the ingredients are suppliedeither separately or mixed together in unit dosage form, for example, asa cryopreserved concentrate in a hermetically sealed container such asan ampoule indicating the quantity of active agent. When the compositionis to be administered by infusion, it can be dispensed with an infusionbottle containing sterile pharmaceutical grade water or saline. Wherethe composition is administered by injection, an ampoule of sterilewater for injection or saline can be provided so that the ingredientscan be mixed prior to administration.

Pharmaceutically acceptable carriers are determined in part by theparticular composition being administered, as well as by the particularmethod used to administer the composition. Accordingly, there are a widevariety of suitable formulations of pharmaceutical compositions (see,e.g., Alfonso R Gennaro (ed), Remington: The Science and Practice ofPharmacy, formerly Remington's Pharmaceutical Sciences 20th ed.,Lippincott, Williams & Wilkins, 2003, incorporated herein by referencein its entirety). The pharmaceutical compositions are generallyformulated as sterile, substantially isotonic and in full compliancewith all Good Manufacturing Practice (GMP) regulations of the U.S. Foodand Drug Administration.

In one aspect, the bioactive cell formulation also includes a cellviability agent. selected from the group consisting of an antioxidant,an oxygen carrier, an immunomodulatory factor, a cell recruitmentfactor, a cell attachment factor, an anti-inflammatory agent, anangiogenic factor, a wound healing factor, and products secreted frombioactive cells.

Methods of Use

In one aspect, the constructs and formulations of the present inventionare suitable for use in the methods of use described herein. In oneembodiment, the formulations of the present invention may beadministered for the treatment of disease. For example, bioactive cellsmay be administered to a native organ as part of a formulation describedherein. In one embodiment, the bioactive cells may be sourced from thenative organ that is the subject of the administration or from a sourcethat is not the target native organ.

In one embodiment, the present invention provides methods for thetreatment of a kidney disease, in a subject in need with theformulations containing bioactive renal cell populations as describedherein. In another embodiment, the therapeutic formulation contains aselected renal cell population or admixtures thereof. In allembodiments, the formulations are suitable for administration to asubject in need of improved kidney function.

In another aspect, the effective treatment of a kidney disease in asubject by the methods of the present invention can be observed throughvarious indicators of kidney function. In one embodiment, the indicatorsof kidney function include, without limitation, serum albumin, albuminto globulin ratio (A/G ratio), serum phosphorous, serum sodium, kidneysize (measurable by ultrasound), serum calcium, phosphorous:calciumratio, serum potassium, proteinuria, urine creatinine, serum creatinine,blood nitrogen urea (BUN), cholesterol levels, triglyceride levels andglomerular filtration rate (GFR). Furthermore, several indicators ofgeneral health and well-being include, without limitation, weight gainor loss, survival, blood pressure (mean systemic blood pressure,diastolic blood pressure, or systolic blood pressure), and physicalendurance performance.

In another aspect, an effective treatment with a bioactive renal cellformulation is evidenced by stabilization of one or more indicators ofkidney function. The stabilization of kidney function is demonstrated bythe observation of a change in an indicator in a subject treated by amethod of the present invention as compared to the same indicator in asubject that has not been treated by a method of the present invention.Alternatively, the stabilization of kidney function may be demonstratedby the observation of a change in an indicator in a subject treated by amethod of the present invention as compared to the same indicator in thesame subject prior to treatment. The change in the first indicator maybe an increase or a decrease in value. In one embodiment, the treatmentprovided by the present invention may include stabilization of serumcreatinine levels in a subject where the BUN levels observed in thesubject are lower as compared to a subject with a similar disease statewho has not been treated by the methods of the present invention. In oneother embodiment, the treatment may include stabilization of serumcreatinine levels in a subject where the serum creatinine levelsobserved in the subject are lower as compared to a subject with asimilar disease state who has not been treated by the methods of thepresent invention. In one embodiment, the stabilization of one or moreof the above indicators of kidney function is the result of treatmentwith a selected renal cell formulation.

Those of ordinary skill in the art will appreciate that one or moreadditional indicators described herein or known in the art may bemeasured to determine the effective treatment of a kidney disease in thesubject.

In another aspect, an effective treatment with a bioactive renal cellformulation is evidenced by improvement of one or more indicators ofkidney function. In one embodiment, the bioactive renal cell populationprovides an improved level of serum creatinine). In another embodiment,the bioactive renal cell population provides an improved retention ofprotein in the serum. In another embodiment, the bioactive renal cellpopulation provides improved levels of serum cholesterol and/ortriglycerides. In another embodiment, the bioactive renal cellpopulation provides an improved level of Vitamin D. In one embodiment,the bioactive renal cell population provides an improvedphosphorus:calcium ratio as compared to a non-enriched cell population.In another embodiment, the bioactive renal cell population provides animproved level of hemoglobin as compared to a non-enriched cellpopulation. In a further embodiment, the bioactive renal cell populationprovides an improved level of serum creatinine as compared to anon-enriched cell population. In one embodiment, the improvement of oneor more of the above indicators of kidney function is the result oftreatment with a selected renal cell formulation.

In another aspect, the present invention provides formulations for usein methods for the regeneration of a native kidney in a subject in needthereof. In one embodiment, the method includes the step ofadministering or implanting a bioactive cell population, admixture, orconstruct described herein to the subject. A regenerated native kidneymay be characterized by a number of indicators including, withoutlimitation, development of function or capacity in the native kidney,improvement of function or capacity in the native kidney, and theexpression of certain markers in the native kidney. In one embodiment,the developed or improved function or capacity may be observed based onthe various indicators of kidney function described above. In anotherembodiment, the regenerated kidney is characterized by differentialexpression of one or more stem cell markers. The stem cell marker may beone or more of the following: SRY (sex determining region Y)-box 2(Sox2); Undifferentiated Embryonic Cell Transcription Factor (UTF1);Nodal Homolog from Mouse (NODAL); Prominin 1 (PROM1) or CD133 (CD133);CD24; and any combination thereof (see Ilagan et al. PCT/US2011/036347incorporated herein by reference in its entirety). In anotherembodiment, the expression of the stem cell marker(s) is up-regulatedcompared to a control.

In another embodiment, the effect may be provided by the cellsthemselves and/or by products secreted from the cells. The regenerativeeffect may be characterized by one or more of the following: a reductionin epithelial-mesenchymal transition (which may be via attenuation ofTGF-β signaling); a reduction in renal fibrosis; a reduction in renalinflammation; differential expression of a stem cell marker in thenative kidney; migration of implanted cells and/or native cells to asite of renal injury, e.g., tubular injury, engraftment of implantedcells at a site of renal injury, e.g., tubular injury; stabilization ofone or more indicators of kidney function (as described herein);restoration of erythroid homeostasis (as described herein); and anycombination thereof.

As an alternative to a tissue biopsy, a regenerative outcome in thesubject receiving treatment can be assessed from examination of a bodilyfluid, e.g., urine. It has been discovered that microvesicles obtainedfrom subject-derived urine sources contain certain components including,without limitation, specific proteins and miRNAs that are ultimatelyderived from the renal cell populations impacted by treatment with thecell populations of the present invention. These components may includefactors involved in stem cell replication and differentiation,apoptosis, inflammation and immuno-modulation. A temporal analysis ofmicrovesicle-associated miRNA/protein expression patterns allows forcontinuous monitoring of regenerative outcomes within the kidney ofsubjects receiving the cell populations, admixtures, or constructs ofthe present invention.

In another embodiment, the present invention provides methods ofassessing whether a kidney disease (KD) patient is responsive totreatment with a therapeutic formulation. The method may include thestep of determining or detecting the amount of vesicles or their luminalcontents in a test sample obtained from a KD patient treated with thetherapeutic, as compared to or relative to the amount of vesicles in acontrol sample, wherein a higher or lower amount of vesicles or theirluminal contents in the test sample as compared to the amount ofvesicles or their luminal contents in the control sample is indicativeof the treated patient's responsiveness to treatment with thetherapeutic.

These kidney-derived vesicles and/or the luminal contents of kidneyderived vesicles may also be shed into the urine of a subject and may beanalyzed for biomarkers indicative of regenerative outcome or treatmentefficacy. The non-invasive prognostic methods may include the step ofobtaining a urine sample from the subject before and/or afteradministration or implantation of a cell population, admixture, orconstruct described herein. Vesicles and other secreted products may beisolated from the urine samples using standard techniques includingwithout limitation, centrifugation to remove unwanted debris (Zhou etal. 2008. Kidney Int. 74(5):613-621; Skog et al. U.S. Published PatentApplication No. 20110053157, each of which is incorporated herein byreference in its entirety).

Methods and Routes of Administration

The bioactive cell formulations of the present invention can beadministered alone or in combination with other bioactive components.The formulations are suitable for injection or implantation ofincorporated tissue engineering elements to the interior of solid organsto regenerate tissue. In addition, the formulations are used for theinjection or implantation of tissue engineering elements to the wall ofhollow organs to regenerate tissue.

In one aspect, the present invention provides methods of providing abioactive cell formulation described herein to a subject in need. In oneembodiment, the source of the bioactive cell may be autologous orallogeneic, syngeneic (autogeneic or isogeneic), and any combinationthereof. In instances where the source is not autologous, the methodsmay include the administration of an immunosuppressant agent. (see e.g.U.S. Pat. No. 7,563,822).

The treatment methods of the subject invention involve the delivery of abioactive cell formulation described herein. In one embodiment, directadministration of cells to the site of intended benefit is preferred. Asubject in need may also be treated by in vivo contacting of a nativekidney with a bioactive cell formulation described herein together withproducts secreted from one or more enriched renal cell populations,and/or an admixture or construct containing the same. The step of invivo contacting provides a regenerative effect to the native kidney.

A variety of means for administering compositions of selected renalcells to subjects will, in view of this specification, be apparent tothose of skill in the art. Such methods include injection of the cellsinto a target site in a subject.

Modes of administration of the formulations include, but are not limitedto, systemic, intra-renal (e.g., parenchymal), intravenous orintra-arterial injection and injection directly into the tissue at theintended site of activity. Additional modes of administration to be usedin accordance with the present invention include single or multipleinjection(s) via direct laparotomy, via direct laparoscopy,transabdominal, or percutaneous. Still yet additional modes ofadministration to be used in accordance with the present inventioninclude, for example, retrograde and ureteropelvic infusion. Surgicalmeans of administration include one-step procedures such as, but notlimited to, partial nephrectomy and construct implantation, partialnephrectomy, partial pyelectomy, vascularization withomentum±peritoneum, multifocal biopsy needle tracks, cone or pyramidal,to cylinder, and renal pole-like replacement, as well as two-stepprocedures including, for example, organoid-internal bioreactor forreplanting. In one embodiment, the formulations containing admixtures ofcells are delivered via the same route at the same time. In anotherembodiment, each of the cell compositions comprising the controlledadmixture are delivered separately to specific locations or via specificmethodologies, either simultaneously or in a temporally-controlledmanner, by one or more of the methods described herein. In oneembodiment, the selected renal cells are percutaneously injected intothe renal cortex of a kidney. In another embodiment, a guiding cannulais inserted percutaneously and used to puncture the kidney capsule priorto injection of the composition into the kidney.

A laparoscopic or percutaneous technique may be used to access thekidney for injection of formulated BRC or SRC population. Use oflaparoscopic surgical techniques allows for direct visualization of thekidney so that any bleeding or other adverse events can be spottedduring injection and addressed immediately. Use of a percutaneousapproach to the kidney has been in use for over a decade, primarily forablating intrarenal masses. These procedures insert an electrode orcryogenic needle into a defined mass in the kidney, and remain incontact for (typically) 10 to 20 minutes while the lesion is ablated.For injection of the therapeutic formulation, the percutaneousinstrumentation is no larger nor more complex, and this approach offersthe safety advantages of no surgery (avoiding abdominal puncture woundsand inflation with gas) and minimal immobilization time. Furthermore,the access track can have hemostatic biodegradable material left inplace, to further reduce any chance of significant bleeding.

According to one embodiment of the delivery by injection, thetherapeutic bioactive cell formulation is injected into the renalcortex. It is important to distribute the therapeutic formulation in therenal cortex as widely as possible, which can be achieved, for example,by entering the renal cortex at an angle allowing deposition of thetherapeutic formulation in the renal cortex, distributed as widely asfeasible. This could require imaging the kidney in a longitudinal ortransverse approach using ultrasound guidance or with axial computedtomography (CT) imaging, depending upon individual patientcharacteristics. Ideally the injection will involve multiple deposits asthe injection needle/cannula is gradually withdrawn. The full volume ofthe therapeutic formulation may be deposited at a single or multipleentry points. In one embodiment, up to two entry points may be used todeposit the full volume of therapeutic formulation into the kidney. Inone embodiment, the injection may be administered to a single kidney,using one or more entry points, e.g. one or two entry points. In anotherembodiment, the injection is made into both kidneys, in each kidneyusing one or more entry point, e.g. one or two entry points.

Chronic Kidney Disease

Chronic Kidney Disease (CKD) is characterized by progressive nephropathythat without therapeutic intervention will worsen until the patientreaches end stage renal disease (ESRD). It is defined as reduced kidneyfunction, demonstrated by decreased estimated glomerular filtration(eGFR) or evidence of kidney damage, such as increased excretion ofurinary albumin. Global prevalence of CKD is estimated at 8-16%. (Jha etal. Chronic kidney disease: global dimension and perspectives. Lancet.2013; 382:260-72.) CKD is associated with considerable morbidity, suchas diabetes mellitus, (Postma and de Zeeuw. The economic benefits ofpreventing end-stage renal disease in patients with type 2 diabetesmellitus. Nephrol Dial Transplant. 2009; 24:2975-2983) and is oftenaccompanied by adverse outcomes owing to underlying disease states orand/or risk factors such as hypertension and renovascular disease. (Khanet al. Health care utilization among patients with chronic kidneydisease. Kidney Int. 2002; 62:229-236) Ninety-seven percent of patientswith moderate to severe CKD have mostly asymptomatic Stage 3 disease,but even this stage of CKD bears a two- to four-fold rise incardiovascular disease risk along with a significant increase inall-cause mortality. (Keith et al. Longitudinal follow-up and outcomesamong a population with chronic kidney disease in a large managed careorganization. Arch Intern Med. 2004; 164:659-63; Gansevoort et al.Chronic kidney disease and cardiovascular risk: epidemiology,mechanisms, and prevention. Lancet. 2013; 382:339-52) Only a smallproportion of patients progress to ESRD (ie, Stage 5 disease); even withcostly treatments, however, patients with ESRD experience substantialmorbidity and mortality. (Keith et al. Longitudinal follow-up andoutcomes among a population with chronic kidney disease in a largemanaged care organization. Arch Intern Med. 2004; 164:659-63) Tosurvive, ESRD patients require renal replacement therapy (dialysis orkidney transplantation). Preventing or delaying adverse outcomes of CKDvia early intervention is the primary strategy in CKD management.(National Institute for Health and Clinical Excellence (NICE). Chronickidney disease: early identification and management of chronic kidneydisease in adults in primary and secondary care (CG182) London: NICE;2014) Nevertheless, early treatments have been less than optimal,resulting in a significant unmet medical need for improvedinterventional strategies to manage CKD and delay progression to ESRD.

Progressive Staging of CKD

The major causes of CKD are diabetes and hypertension. Nearly half ofall CKD cases arise from diabetes with or without hypertension. (Postmaand de Zeeuw. The economic benefits of preventing end-stage renaldisease in patients with type 2 diabetes mellitus. Nephrol DialTransplant. 2009; 24:2975-2983; Gansevoort et al. Chronic kidney diseaseand cardiovascular risk: epidemiology, mechanisms, and prevention.Lancet. 2013; 382:339-52) The incidence of CKD continues to increase,primarily due to the increased incidence of Type 2 Diabetes Mellitus(T2DM). (Postma and de Zeeuw. Nephrol Dial Transplant. 2009;24:2975-2983)

Staging and grading of kidney function is most often quantified by theestimated glomerular filtration rate (GFR), which is defined as “thevolume of plasma from which a given substance is completely cleared byglomerular filtration per unit time”. (Stevens et al. Assessing kidneyfunction—Measured and estimated glomerular filtration rate. New Engl JMed. 2006; 354:2473-83) Creatinine clearance is the principal endogenousmarker that is used to measure GFR. In February 2002, with the aim ofproviding a uniform definition of CKD, the Kidney Disease OutcomesQuality Initiative of the US Kidney Foundation defined CKD and thevarious stages of CKD (Table 1) (Levey et al. National Kidney Foundationpractice guidelines for chronic kidney disease: evaluation,classification, and stratification. Ann Int Med. 2003; 139:137-47). Forexample, the threshold for CKD is 60 mL/min/1.73 m², which is less thanone-half of the GFR for a normal, young adult male (120-130 mL/min/1.73m²). (Levey et al. Definition and classification of chronic kidneydisease: apposition statement from Kidney Disease Improving GlobalOutcomes (KDIGO). Kidney Int. 2005; 67:2089-100) Additionally, there isa heightened risk for CKD complications when the GFR is 60 mL/min/1.73m² and lower.

Table 1 defines CKD stages according to GFR measurements, and therelative prevalence and clinical action taken at each stage. (NationalKidney Foundation, 2002. KDOQI clinical practice guidelines for chronickidney disease: evaluation, classification, and stratification. Am JKidney Dis. 39:S1-266) The initial stage of diabetic nephropathy(Stage 1) occurs over a period of several years and is characterized bymicroalbuminuria (30-300 mg/24 hr) followed by macroalbuminuria (>300mg/24 hr). As the ability of the kidney to filter blood waste productsdeclines, serum creatinine rises. With increasing kidney damage (Stages2-4), rising blood pressure further exacerbates kidney disease. When thekidneys cease to function entirely (Stage 5 [ESRD]), renal replacementtherapy (dialysis or transplantation) is required.

TABLE 1 Summary of Classification and Prevalence Estimates for CKD GFRStage* Description (mL/min/1.73 m²) 1 Kidney damage with normal orincreased >90 GFR 2 Kidney damage with mild decrease in GFR   60-89 3Moderate decrease in GFR   30-59 4 Severe decrease in GFR   15-29 5Kidney failure <15 (or dialysis) *Source: National Kidney Foundation,2002. National Kidney Foundation. 2002. KDOQI clinical practiceguidelines for chronic kidney disease: evaluation, classification, andstratification. Am J Kidney Dis. 39:S1-266.

All-cause mortality rates were shown to increase as GFR declined;mortality rates were highest at Stages 4-5 of CKD. (Go et al. Chronickidney disease and the risks of death, cardiovascular events, andhospitalization. N Engl J Med. 2004; 351:1296-305; Astor et al.Glomerular filtration rate, albuminuria, and risk of cardiovascular andall-cause mortality in the US population. Am J Epidemiol. 2008;167:1226-34; Kovesdy et al. Association of kidney function withmortality in patients with chronic kidney disease not yet on dialysis: ahistorical prospective cohort study. Adv Chronic Kidney Dis. 2006;13:183-88) Populations defined as having an eGFR <60 mL/min/1.73 m²consistently exhibited a higher mortality rate than comparator groupswhere there was no evidence of CKD.

Standard-of-Care in CKD

Treatment of patients with CKD is focused on slowing progression andpreparing for kidney failure/replacement. For many patients, CKD occursas part of a complex comorbidity cluster, especially with cardiovasculardisease and T2DM.

Increased risk of cardiovascular disease can be a complication of CKD oran independent comorbidity associated with T2DM. (Gerstein et al.Albuminuria and risk of cardiovascular events, death, and heart failurein diabetic and nondiabetic individuals. JAMA. 2001; 286:421-26)Collectively, the aim is to lower cardiovascular risk and prevent orslow the progression of kidney failure via administration of: 1)angiotensin converting enzyme inhibitors (ACEI) and/or angiotensinreceptor blockers (ARB) to decrease proteinuria and controlhypertension; 2) insulin and anti-diabetic agents for glycemic control(eg, reduced serum hemoglobin AO; and, 3) statin therapy to counterdyslipidemia.

When a patient reaches ESRD, renal replacement therapy (ie, dialysis ortransplantation) is indicated. The vast majority of Stage 5 patientsreceive hemodialysis. (Dhingra et al. Type of vascular access andmortality in US hemodialysis patients. Kidney Int. 2001; 60:1443-51)Dialysis replaces about 5-15% of kidney function, depending on theintensity and frequency of use; dialysis also helps to restore fluid andelectrolyte balance when kidneys fail. However, the life-expectancy ofan ESRD patient initiating hemodialysis is only 4-5 years. (US RenalData System. 2012 Annual data report: Atlas of chronic kidney diseaseand end-stage renal disease in the US. National Institutes of Health,National Institute of Diabetes and Digestive and Kidney Diseases,Bethesda, Md.) Additionally, hemodialysis has been associated withmultiple, serious complications as well as interference with quality oflife, such as the need to undergo dialysis up to three times per week.Although kidney transplantation remains the most effective form oftherapy at this time; there is a chronic shortage of organs. If apatient is able to secure a kidney for transplantation, long-termimmunosuppressive therapy is required to prevent rejection. Use of theseregimens results in a higher incidence of infection and, over the longterm, some types of cancer. (Almeida et al. Safety of immunosuppressivedrugs used as maintenance therapy in kidney transplantation: asystematic review and meta-analysis. Pharmaceuticals (Basel). 2013;6:1170-94) Taken together, there is a critical medical need for improvedtherapies for CKD which could dramatically slow the progression ofdisease and significantly delay the need for renal transplantation.

Therapeutic Product:

The Neo Kidney Augment™ (NKA) is being developed based on extensivescientific evaluation of its biologically active component known as SRC(ie, homologous, autologous selected renal cells). This cell populationis naturally involved in renal repair and regeneration. (Bruce et al.Selected renal cells modulate disease progression in rodent models ofchronic kidney disease via NF-κB and TGF-β1 pathways. Regen Med. 2015;10:815-39; Bruce et al. Exposure of cultured human renal cells inducesmediators of cell migration and attachment and facilitates the repair oftubular cell monolayers in vitro. Experimental Biology Meeting,Washington, D C, 2011; Genheimer et al. Molecular characterization ofthe regenerative response induced by intrarenal transplantation ofselected renal cells in a rodent model of chronic kidney disease. CellsTissues Organs. 2012; 196:374-84; Ilagan et al. Exosomes derived fromprimary renal cells contain microRNAs that can potentially drivetherapeutically-relevant outcomes in models of chronic kidney disease.TERMIS Conference, Orlando, Fla., 2010; Ilagan et al. Secreted factorsfrom bioactive kidney cells attenuate NF-kappa-B. TERMIS Conference,Orlando, Fla., 2010; Ilagan et al. Characterization of primary adultcanine renal cells (CRC) in a three-dimensional (3D) culture systempermissive for ex vivo nephrogenesis. KIDSTEM Conference, Liverpool, UK, 2009; Kelley et al. A population of selected renal cells augmentsrenal function and extends survival in the ZSF-1 model of progressivediabetic nephropathy. Cell Transplant. 2013; 22:1023-39; Kelley et al.Intra-renal transplantation of bioactive renal cells preserves renalfunctions and extends survival in the ZSF-I model of progressivediabetic nephropathy. ADA Conference, San Diego, Calif., 2011; Kelley etal. Bioactive renal cells augment kidney function in a rodent model ofchronic kidney disease. ISCT Conference, Philadelphia, Pa., 2010; Kelleyet al. Enhanced renal cell function in dynamic 3D culture system.KIDSTEM Conference, Liverpool, U K, 2008; Kelley et al. Bioactive renalcells augment renal function in the ZSF-1 model of diabetic nephropathy.TERMIS Conference, Orlando, Fla., 2010; Presnell et al. Isolation,characterization, and expansion (ice) methods for defined primary renalcell populations from rodent, canine, and human normal and diseasedkidneys. Tissue Engineering Part C Methods. 2010; 17:261-73; Presnell etal. Isolation and characterization of bioresponsive renal cells fromhuman and large mammal with chronic renal failure. Experimental BiologyMeeting, New Orleans, L A, 2009; Wallace et al. Quantitative ex vivocharacterization of human renal cell population dynamics viahigh-content image-based analysis (hca). ISCT Conference, Philadelphia,Pa., 2010; Yamaleyeva et al. Primary human kidney cell culturescontaining erythropoietin-producing cells improve renal injury. TERMISConference, Orlando, Fla., 2010) Therapeutic intervention with NKA isintended to improve renal function in subjects with CKD and T2DM anddelay the need for renal dialysis or transplantation which, based on thecurrent standard-of-care, is inevitable for ESRD.

NKA is made from expanded autologous selected renal cells (SRC) obtainedfrom each individual subject's kidney biopsy. To manufacture NKA, kidneybiopsy tissue from each enrolled subject will be processed to have renalcells expanded and SRC selected. SRC will be formulated in a gelatinbased hydrogel at a concentration of 100×10⁶ cells/mL, packaged in a 10mL syringe, and shipped to the clinical site for use.

Treatment Regimen

Therapeutic Dose Selection

The appropriate cell implantation dosage in humans can be determinedfrom existing information relating to either the activity of the cellsor extrapolated from dosing studies conducted in preclinical studies.Multiple animal studies conducted using a wide range of doses (3-15million cells per gram of kidney tissue injected), and extended periodsof time post-treatment (up to one year) have demonstrated the ability ofNKA to positively affect renal outcomes in different models of renalinsufficiency and disease. From in vitro culture and in vivo animalexperiments, the amount of cells can be quantified and used incalculating an appropriate dosage of implanted material. Additionally,the patient can be monitored to determine if additional implantation canbe made or implanted material reduced accordingly.

In one embodiment, NKA is presented in a sterile, single-use syringe.The final volume is calculated from the concentration of 100×10⁶ SRC/mLof NKA and the target dose of 3.0×10⁶ SRC/g kidney weight (estimated byMRI). As described in the literature, volume measurements of the kidneyin mLs obtained by different methods are approximately 92-97% of dryweight measurements in grams obtained by measuring isolated organstrimmed of perirenal fat. Therefore, as a conservative estimation, dosesof NKA will be calculated using a conversion of 1 g equals 1 mL. Usingthis ratio represents the safest approach as it guarantees patients willnot receive doses higher than corresponding doses in animal studies.Dosage will be determined by the surgeon at the time of injection basedon the patient's kidney weight. The maximum volume for any patient willbe 8.0 mL; that is, if any subject has a left kidney with a calculatedweight ≧259 g, then that subject will receive 8 mL of NKA.

Number of Treatments

Expanded renal cells can be cryopreserved during cell expansion toaccommodate for patient-dependent variation in cell expansion.Cryopreserved renal cells provide a continuing source of cells tomanufacture multiple doses of the bioactive cell formulation forre-injection and in the event that another treatment is needed (e.g.,delay due to patient sickness, unforeseen process events, etc.).

In one embodiment, the BRC or SRC are administered as a single treatmentinto one kidney. In another embodiment, the BRC or SRC are administeredas a single treatment with injections into both kidneys. In anotherembodiment, the BRC or SRC are administered as repeated or multipleinjections into one or both kidneys. In yet another embodiment, thefirst and second injections are administered at least 3 months apart, atleast 6 months apart, or at least one year apart. In still yet anotherembodiment, the BRC or SRC are administered over more than 2 injections.

The following examples are offered for illustrative purposes only, andare not intended to limit the scope of the present invention in any way.

EXAMPLES Example 1—Phase I, Open-Label Safety and Delivery OptimizationStudy of an Autologous Neo-Kidney Augment (NKA) in Patients with ChronicKidney Disease (TNG-CL010)

A first-in-human (FIH) clinical trial was initiated at the KarolinskaUniversity Hospital Huddinge in Stockholm, Sweden and the University ofNorth Carolina. The trial was a Phase 1, open-label, safety andinjection optimization study of NKA injected into patients with CKD. NKAwas manufactured from SRC obtained from a patient's biopsy, formulatedwith gelatin biomaterial, and injected back into the patient's leftkidney. The primary objective of the study was to assess the safety andoptimal injection of NKA injected at one site in a recipient kidney asmeasured by procedure and/or product related adverse events (AEs)through 12 months post-injection. The secondary objective of the studywas to assess changes in renal function over a 12 month period followinginjection as measured by laboratory assessments. Each patient's baselinerate of disease progression was used as the control to monitor foradverse changes in the rate of disease progression following injection.

Materials and Methods Treatment Protocol

Patients

Seven adult type-2 diabetic CKD stage 3-4 patients at the Department ofRenal Medicine, Karolinska University Hospital, Stockholm, Sweden (n=6)and Department of Renal Medicine, University of North Carolina at ChapelHill, USA (n=1) were recruited for the study. The study was approved bythe regional committees of ethics in Stockholm and Chapel Hill andadhered to the statutes of the Declaration of Helsinki. All patientsprovided written consent of participation.

In brief, adult (age 53-70 years) type-2 diabetic patients with GFR of15-50 ml/min and clinical course compatible with diabetic nephropathy,ongoing ACEi/ARB treatment and a kidney size >10 cm (corticalthickness >5 mm) were eligible for inclusion. Patients who satisfied theeligibility criteria and signed informed consent entered a screeningphase including full physical examination, electrocardiograms andlaboratory assessments (hematology, serum chemistry and urinalysis). Inaddition, an MRI was performed to assess kidney volume and cortexthickness. Renal scintigraphy was performed to assess split kidneyfunction. Eligible patients underwent a kidney biopsy according to thestandard clinical procedure (two cores) to obtain the cells forimplantation. The study protocol is depicted in FIG. 1.

Preparation of Neo-Kidney Augment (NKA)

Briefly, biopsies were dissociated enzymatically in a buffer containing4.0 units/mL dispase (Stem Cell Technologies, Inc., Vancouver, BC,Canada) and 300 units/mL collagenase IV (Worthington Biochemical,Lakewood, N.J., USA). Red blood cells and debris were removed bycentrifugation through 15% iodixanol (Optiprep®, Axis Shield, Norton,Mass., USA). Primary renal cells were seeded onto tissue culture treatedpolystyrene plates (NUNC, Rochester, N.Y., USA) and cultured in 50:50media, a 1:1 mixture of high glucose Dulbecco's Modified Eagle Medium(DMEM): Keratinocyte Serum Free Medium (KSFM) containing 5% Fetal BovineSerum (FBS), 1×ITS (insulin/transferrin/sodium selenite mediumsupplement), and antibiotic/antimycotic (all from Invitrogen, Carlsbad,Calif., USA). Prior to post-culture cell separation, primary renal cellcultures were transferred from atmospheric oxygen conditions (21%) to amore physiologically relevant low-oxygen (2%) environment for 24 hours,to improve cell separation efficiency. Separation of primary renal cellcultures, prepared as 75×106 cells in 2 mL unsupplemented KSFM (uKSFM),was performed by centrifugation through a four-step iodixanol (OptiPrep;60% w/v in uKSFM) density gradient layered specifically for rodent (16%,13%, 11%, and 7%) in 15 mL conical polypropylene tubes and centrifugedat 800 g for 20 min at room temperature. After centrifugation all bandswere washed 3 times with sterile phosphate buffered saline (PBS) priorto use.

Combining bioactive renal cells that exhibit a buoyant density greaterthan approximately 1.0419 g/mL from the density gradient centrifugationstep, produced therapeutically bioactive SRCs. The preparation ofselected renal cells from patient biopsies is also described, forexample, in Kelley et al. (Am J Physiol Renal Physiol 2010; 299:F1026-39), Kelley et al. (Cell Transplant 2013; 22:1023-39), Bruce etal. (Methods Mol Biol. 2013; 1001:53-64) and Basu et al. (CellTransplant. 2011; 20:1171-901). Cell suspensions (1004) were loaded intoa 10 cc syringe mixed with gelatin-based hydrogel biomaterial toformulate the NKA product.

Cell viability is measured at each culture passage and during NKAformulation (Trypan Blue Exclusion). Assays of cell phenotype andpotency are performed on the final NKA product as previously described(Basu and Ludlow. Regen Med 2014; 9:497-512). All procedures areconducted in compliance with current Good Manufacturing Practices (cGMP)under the guidance of FDA and MPA QP.

Implantation Procedure

In the Swedish cases (patient #1-6) a Pfannenstiel incision was made anda hand-assist device placed in the wound (Gelport©, Applied MedicalResources Corporation). Moving the peritoneum medially by blunt manualdissection created a retroperitoneal space (Wadström J. Transplantation.2005; 80:1060-8). The medio-anterial portion of Gerota's fascia of theleft kidney was opened to expose the pen-renal fatty tissue, which wasabundant in all cases. The fatty tissue was removed to expose the kidneycapsule, essentially all of the medial and lateral aspects as well asalmost the entire convex/lateral part of the kidney. The extensivedissection allowed to position the kidney in alignment with theinjecting needle and to visualize if there was any penetration orleakage of the injected material. From the left iliac fossa a guidingcannula was inserted transcutaneously to puncture the kidney capsule atthe lower pole. An 18G needle was thereafter inserted through theguiding cannula into the renal cortex along the convex longitudinal axisof the kidney. Two mL of NKA was deposited at 4, 3, 2 and 1 cm from thepuncture of the capsule over a 10-15 minute time period (total 8 mL).The needle was kept in place 5 minutes to promote haemostasis. Noper-operative bleeding and only minimal amounts of NKA (<1 mL) was seenbacking out of the puncture hole in any of the procedures. The wound wasnot drained and the abdominal wall was closed with a running suture. TheUS patient (#7) underwent robot-assisted laparoscopic renal cellimplantation in the left renal cortex. Dosing of NKA was determined byestimated kidney weight (the maximum volume for any patient was 8 mL,which all subjects received).

MR Imaging

MRI was performed before implantation (<30 days) and 3 and 6 monthsafter using a 1.5-T MR unit (Siemens Magnetom Aera, Siemens AEG,Erlangen, Germany). Cortical thickness was measured in the dorsal partof the upper pole of the kidney using a 4 mm thick axial T2Haste image.Kidney volume was quantified by manual segmentation using a dataset ofbreath hold 2.5 mm thick VIBE images obtained without fat saturation.

Renal Scintigraphy

Kidney function was evaluated in the supine position 3 hours afterintravenous injection of 50 MBq ^(99m)Tc-DMSA (CIS bio international,Gif sur Yvette Cedex, France). An anterior and posterior acquisitionwith a preset time of 20 minutes using a double headed gamma camera(Symbia T16 SPECT/CT, Siemens, Erlangen, Germany) equipped withlow-energy high-resolution collimator, 256×256 matrix. Differentialrenal function was assessed using region-of-interest drawings includingentire kidney with a geometrical mean calculated from both projections.

Biochemical and Other Analyses

Analyses of high-sensitivity C-reactive protein (hsCRP), creatinine,cystatin C, iohexol clearance, haemoglobin, albumin, Ca, PO₄, andalbumin-creatinine ratio (ACR) were performed with validated routinemethods at the certified Clinical Laboratory of Karolinska UniversityHospital, Stockholm, Sweden and Chapel Hill, N.C., USA.

Statistical Analyses

Data are expressed as mean±SEM. Statistical significance was set at thelevel of p<0.05.

Results

Estimated Glomerular Filtration Rate (eGFR)

The cohort of patients injected with NKA underwent a pre-injectionassessment of the progress of their kidney disease and were consistentwith a Hemmelgarn Moderate Group decline in eGFR of 5-10 ml/min/1.73 m³(see e.g. Hemmelgarn et al, Kid Intern; 2006, which shows the divisionof community-dwelling elderly patients in 5 groups based on the rate ofchange in mean eGFR).

Pre-injection information from this patient cohort indicated that theiraverage decline in eGFR was 6.1 ml/min/year (FIG. 2). Post NKAadministration, eGFR decline for the combined group of 7 patients (6patients from the Swedish study and 1 patient from the American study)was −3.1 ml/min/year (FIG. 2). The average post-injectionrate-of-decline for eGFR in the cohort is shown by the green line andthe shaded blue area represents the range of eGFR for the Hemmelgarngroup of community-dwelling elderly patients with moderately severe CKD3b/4 with an annual decline of 5-10 ml/min/year (shaded area in FIG. 2).

The eGFR changes for individual patients' post-injection of NKA alongwith the patient's individual pre-injection decline demonstrated that 6of 7 patients had a reduction in the rate of decline in eGFR over theperiod patients were on study (FIG. 3). The annual rate of eGFR declinepre and post injection for each patient is shown in the Table 2.

TABLE 2 Change in Estimated Glomerular Filtration Rate by Patient Changein eGFR (mL/min/year) Patient # Pre-NKA Post-NKA Patient 1 −14.8 1.5Patient 2 −0.2 −1.3 Patient 3 −6.7 −5.9 Patient 4 −16.3 −7.5 Patient 5−3.9 −2.6 Patient 6 −11.4 −5.9 Patient 7 −7.7 1.4

In summary, 6 of the 7 patients had a reduction in the rate (slope) ofeGFR decline after NKA injection. The pre-injection rate-of-decline ineGFR for the NKA cohort was 6.1 ml/min/year, consistent withHemmelgarn's study of community-dwelling elderly patients.

Patient #2 continued at approximately the same rate of decline asobserved during the pre-injection period. Over the short period of eGFRsampling prior to NKA injection in this patient, his eGFR measurementsvaried over a range of ±3 ml/min/1.73 m3. When this patient's eGFR wascompared to the overall cohort of 7 patients, changes in his eGFRfollowed a similar pattern for post-injection as others in the studycohort (FIG. 4). Additionally, this patient's serum creatinine increasewas attenuated suggesting a potential stabilization of progression forCKD (see section on sCr below).

The Phase I Clinical Trials with NKA were conducted using doses of NKAthat were considered likely to be sub-therapeutic, to evaluate theeffects of NKA when injected into a single kidney in a small cohort ofelderly diabetic pre-dialysis patients with CKD 3b/4. In a diabeticanimal model of aggressive chronic kidney disease, the optimal outcomesof delaying death from end-stage kidney disease were obtained whenanimals were treated in both kidneys. In the interest of safety, in thefirst clinical studies of NKA, only 1 kidney was injected with NKA, andtherefore a therapeutic signal was not necessarily expected. However,after monitoring the progress of CKD in this cohort of patients for ˜1year, the decline in renal function projected for this cohort wasmodified by a single injection of NKA into a single kidney (left). Whenthe rates of decline of renal function pre- and post-injection arecompared, the NKA injected patients have an imputed delay in dialysis ofover 1.5 years (FIG. 5).

Serum Creatinine (sCr)

Serum creatinine levels for the cohort of patients pre-injection showeda general increase consistent with what would be expected in diabeticpatients with moderate CKD (red-line). The overall pre-injectionincrease in sCr for the cohort of patients was >100 mole/L/yr.Post-injection the cohort of patients had an increase <50 mole/L/yr(green line). The overall trends in SCr before and after injection areshown in FIG. 6. Individual patient serum creatinine changes,post-injection of NKA (green) along with the patient's individualpre-injection decline are shown in FIG. 7. The annual rates of increaseof serum creatinine before and after NKA injection for each patient areshown in Table 3.

TABLE 3 Change in Serum Creatinine by Patient Change in sCr(μmole/L/year) PT # Pre-NKA Post-NKA Patient 1 153 −41 Patient 2 17 −21Patient 3 214 200 Patient 4 16 −39 Patient 5 69 23 Patient 6 216 95Patient 7 48 −40

In summary, after NKA injection, all patients had a reduction in theirindividual rate of increase for sCr compared to the rate of sCr increasethat had been observed in the pre-injection period. This change wasconsistent for each patient and supports the effects observed for eGFRin the after NKA injection period.

Example 2—Phase II, Open-Label Safety and Efficacy Study of anAutologous Neo-Kidney Augment (NKA) in Patients with Type 2 Diabetes andChronic Kidney Disease (RMCL-001) Therapeutic Product:

NKA is made from expanded autologous selected renal cell population(SRC) obtained from the patient's kidney biopsy as described inExample 1. To manufacture NKA, kidney biopsy tissue from each enrolledpatient were processed to have renal cells expanded and SRC selected.SRC will be formulated in a gelatin based hydrogel at a concentration of100×10⁶ cells/mL, packaged in a 10 mL syringe, and shipped to theclinical site for use (see example 1).

Study Objectives:

Primary Objective:

The primary objective of the study is to assess the safety and efficacyof NKA injected in one recipient kidney and determine if two injectionsof NKA provide stabilization of renal function.

-   -   Primary Safety Outcome Measures: procedure and/or product        related adverse events (AE's) through 12 months following the        initial NKA injection.    -   Primary Efficacy Outcome Measures: serial measurement of serum        creatinine and estimation of GFR through 6 months following the        second cell injection

Secondary Objective:

The secondary objective of the study is to assess the safety andtolerability of NKA administration by assessing renal-specific adverseevents over a 12 month period following a patient's first NKA injection.

-   -   Secondary Safety and Tolerability Outcome Measures:        renal-specific laboratory assessments through 12 months        following the last NKA injection under this protocol, whether        first or second.

Exploratory Objective:

Exploratory objectives of the study are designed to assess the impact ofNKA on renal function over a 12 month period following the initial NKAinjection.

-   -   Exploratory Outcome Measures: clinical diagnostic and laboratory        assessments of renal structure and function (including eGFR,        serum creatinine, and proteinuria) to assess changes in the rate        of progression of renal disease; and effect of method of        injection on these parameters.    -   Exploratory quality of life outcome measure will be the Kidney        Disease Quality of Life survey obtained at baseline and at 1, 3,        6, 7, 9, 12, 15, 18, 30, and 42 months after a patient's first        NKA injection.

Study Design:

Multi-center, prospective, open-label, single-group study. All enrolledsubjects will be treated with up to two injections of NKA at least 6months apart.

Randomization:

Open-Label, Non-Randomized.

Control Group:

Each subject will serve as his or her own control; the patient'sprevious medical history, which must include a minimum 6 month period ofobservation of renal function, will serve as the comparator for rate ofprogression of renal insufficiency.

Sample Size:

Up to 30 subjects will be injected with NKA. As this is a Phase IIsafety and efficacy study, robust statistical analysis will not beperformed. Therefore, the sample size proposed for this study is a sizetypical for the active treatment group in Phase II studies, allowing foridentification of safety outcomes and early efficacy in a limitedpopulation.

Study Population:

Male or female patients 30 to 70 years of age with Type 2 diabetesmellitus and CKD with eGFR between 20 and 50 mL/min/1.73 m². An enrolledpatient should have sufficient historical clinical data to determine hisor her individual rate of CKD disease progression.

Inclusion Criteria:

Unless otherwise noted, inclusion criteria must be met at Screening andprior to injection.

-   -   1. Male and female subjects, age 30 to 70 years on the date of        informed consent.    -   2. Patients with type 2 diabetes mellitus (T2DM).    -   3. Patients with a well-established diagnosis of diabetic        nephropathy as the underlying cause of their renal disease.    -   4. At screening, patients not previously injected with NKA with        CKD defined as a GFR of 20-50 mL/min/1.73 m² inclusive. Patients        previously treated with a single NKA injection with eGFR 15 to        60 mL/min may also enroll in this clinical trial.    -   5. Microalbuminuria that cannot be explained by an alternative        diagnosis. Microalbuminuria is defined as urinary        albumin-creatinine ratio (UACR) ≧30 mg/g or urine albumin        excretion ≧30 mg/day on 24 hour urine collection.    -   6. Prior to biopsy, systolic blood pressure between 105 and 140        mmHg (inclusive) and diastolic blood pressure ≦90 mmHg.    -   7. Ongoing and stable treatment with ACEI or ARB initiated at        least 8 weeks prior to enrollment. Treatment must be stable for        the 6 weeks immediately prior to injection. Stable treatment is        defined as dose adjustment to no less than ½ of the current        dosage and no more than 2× the current dosage over the 6 week        period immediately prior to injection; dose interruptions of up        to 7 days due to medical necessity are allowed. Patients who are        intolerant to ACEI or ARBs may be included as long as they have        stable BP within the acceptable limits.    -   8. Minimum of 2 measurements of eGFR or sCr taken at least 3        months apart (prior to screening) and within the previous 12        months to define the rate of progression of CKD. The patient        should have sufficient historical data to provide a reasonable        estimate of the rate of progression of CKD as determined        following consultation with the Medical Monitor (to insure        sufficient data is available). In addition, the rate of        progression of CKD must be consistent over time. There is no        defined rate of progression that is required to qualify for        inclusion.    -   9. Willing and able to refrain from use of NSAIDs (including        aspirin) and clopidogrel, prasugrel, or other platelet        inhibitors pen-procedure (i.e., before and after both the biopsy        and injection). The wash-out period before and after each        procedure should be 7 days. Willing and able to refrain from use        of fish oil and dipryridamole for 7 days before and 7 days after        each procedure.    -   10. Willing and able to cooperate with all aspects of the study.    -   11. Willing and able to give signed informed consent.

Exclusion Criteria:

Patients may not be enrolled if they meet any of the exclusion criterialisted below. Criteria should be assessed at Screening and beforeinjection unless noted otherwise.

-   -   1. Type 1 diabetes mellitus (DM).    -   2. History of a renal transplant.    -   3. HbA1c>10% at Screening. Patients with HbA1c>8% at the time of        screening should be offered diabetic teaching and advised to        consult their primary physicians for further diabetic        management.    -   4. Hemoglobin levels <9 g/dL prior to injection. Hemoglobin        levels should be measured within 48 hours before the procedure        or per site standard practice.    -   5. Known allergy to kanamycin or structurally similar        aminoglycoside antibiotics (as kanamycin is used during        manufacture of NKA).    -   6. Abnormal coagulation status as measured by APTT, INR, and/or        platelet count at Screening.    -   7. Not a good candidate for the injection procedure (based on        the assessment of the surgeon who will be performing the        injection) including patients who are morbidly obese, have        excessive fat surrounding the kidney, have BMI>45, or who are        otherwise at excessive risk for serious complications.    -   8. Clinically significant infection requiring parenteral        antibiotics within 6 weeks of injection.    -   9. Patients with small kidneys (average size <9 cm) or only one        kidney, as assessed by MRI or renal US at screening or if        previously done within 1 year of screening.    -   10. Patients with a rapid decline in renal function over the        last 3 months prior to injection or acute kidney injury.    -   11. Patients with any of the following conditions prior to        injection: renal tumors, polycystic kidney disease, renal cysts        or other anatomic abnormalities that would interfere with        injection procedure (e.g., cysts in the pathway of the        injection), hydronephrosis, skin infection over proposed        injection sites, or evidence of a urinary tract infection.    -   12. Female subjects who are pregnant, lactating (breast feeding)        or planning a pregnancy during the course of the study, or who        are of child bearing potential and not using a highly effective        method of birth control (including sexual abstinence). A highly        effective method of birth control is defined as one that results        in a low failure rate (i.e. less than 1 percent per year) when        used consistently and correctly, such as implants, injectables,        combined oral contraceptives, some intrauterine devices (IUDs),        sexual abstinence, or a vasectomized partner. Subjects must be        willing to continue birth control methods throughout the course        of the study.    -   13. History of cancer within the past 3 years (excluding        non-melanoma skin cancer and carcinoma in situ of the cervix).    -   14. Life expectancy of less than 2 years.    -   15. Any contraindication or known anaphylactic or severe        systemic reaction to either human blood products or materials of        animal (bovine, porcine) origin or anesthetic agents.    -   16. Positive for Human Immunodeficiency Virus (HIV), Hepatitis B        Virus (HBV), or Hepatitis C Virus (HCV) assessed at the        Screening Visit.    -   17. Subjects with active tuberculosis (TB) requiring treatment        in the past 3 years.    -   18. Immunocompromised subjects or patients receiving        immunosuppressive agents (including patients treated for chronic        glomerulonephritis) within 3 months of injection. [Note: inhaled        corticosteroids and chronic low-dose corticosteroids [≦7.5 mg        per day] are permitted as are brief pulsed corticosteroids for        intermittent symptoms (e.g. asthma).]    -   19. Subjects with uncontrolled diabetes (defined as        metabolically unstable by the PI), or with incapacitating        cardiac and/or pulmonary disorders.    -   20. History of active alcohol and/or drug abuse that in the        investigator's assessment would impair the subject's ability to        comply with the protocol.    -   21. Patients with clinically significant hepatic disease (ALT or        AST >3.0×ULN) at Screening.    -   22. Patients with bleeding disorders that would, in the opinion        of the Investigator, interfere with the performance of study        procedures; patients taking coumarins (e.g. Warfarin) or other        anticoagulants (e.g. enoxaparin or direct thrombin inhibitors).    -   23. Any circumstance in which the investigator deems        participation in the study is not in the subject's best        interest.    -   24. Use of any investigational product within 3 months of the        injection without receiving prior written consent of the Medical        Monitor.

Study Duration:

Initially designed as 18 months NKA injections follow up followed by 24month long term follow up for a total study duration of 42 months.Subsequently followed patients past protocol out to 4 years.

Study Enrollment:

Up to 30 subjects undergoing NKA injection will be enrolled into thestudy. Patients who have received a single injection of NKA underprevious research protocols may enroll in this clinical trial to receivea single additional injection. Patients who have never received an NKAinjection may enroll in this clinical trial for up to a total of two (2)NKA injections, temporally spaced at least 6 months apart. All biopsiesare to be taken from a single kidney, and all NKA injections are to begiven into the kidney that was biopsied. Patients who complete screeningprocedures satisfying all I/E criteria will be enrolled into the studyimmediately prior to the injection. Patients who do not meet allcriteria before injection will be considered screen failures. Once apatient has been injected, the patient will have completed treatment andevery effort should be made to ensure the patient completes allfollow-up visits. Injection dates for the first 3 patients receivingtheir second NKA injection will be staggered by a minimum of 3 weekintervals to allow for assessment of acute adverse events and othersafety parameters by the DSMB. Subsequent second injections willcontinue to be staggered so as to occur no less than 3 weeks apart, butindividual DMSB review will not be required. At the completion of thefollow-up visits, patients will continue in a long-term follow-up study.Patients will be followed for a total of 36 months following the lastNKA injection under this protocol, whether the first or secondinjection.

Investigational Plan:

Screening:

Subjects who satisfy eligibility criteria may be entered into the study.Subjects must have sufficient historical data on renal function to allowfor determination of the rate of progression of renal disease prior toinjection (Inclusion Criterion 8). Screening procedures will include afull physical examination, electrocardiogram, and laboratory assessments(hematology, serum chemistry, and urinalysis). In addition, an MRI willbe performed to assess kidney volume using site standard practices.

Biopsy:

Patients not previously enrolled in a Phase 1 trial will require a renalbiopsy to obtain the cells for injection. The biopsy specimens obtainedfrom patients previously enrolled in a Phase 1 trial and maintained in afrozen state will be used to generate the second quantum of NKA to beinjected under this protocol, if sufficient cells are available afterthawing. If the number of cells obtained after thawing the frozen biopsyspecimens is insufficient, the patient may need to have an additionalbiopsy procedure completed for this study.

Injection:

Ten to 14 days before the scheduled injection date, subjects will reportto the clinic for verification of final eligibility criteria. Inaddition, a renal scintigraphy study will be performed to obtain abaseline assessment of split kidney function. Subjects who meetappropriate I/E criteria will be admitted to the hospital/clinicalresearch unit early in the morning on the day of scheduled injection(Day 0). NKA will be injected into the biopsied kidney, using one of twoavailable options: (1) a laparoscopic approach; or (2) a percutaneousapproach. The laparoscopic method may utilize robotic assistance tostabilize the kidney while the injection is performed with laparoscopicviewing; while the percutaneous method will employ a standardizedtechnique such as utilized in the ablation of renal masses byradiofrequency or cryogenic methods. Subjects will remain hospitalizedfor a minimum of 2 nights and up to 4 nights following a laparoscopicinjection (or until any procedure- or product-related AE's have resolvedor stabilized). Patients may be discharged the same day following apercutaneous injection without complications. An ultrasound study willbe performed on Day 1 to verify the lack of subclinical adverse effectsfor both approaches.

It is anticipated that all patients will be planned to receive 2injections under this protocol, in order to allow dose-finding and tounderstand the duration of effect. Under certain circumstances a patientor investigator may decide to postpone or withhold the second dose. Ingeneral, if there appears to be any untoward safety risk, in situationsincluding rapid deterioration of renal function, the development ofuncontrolled diabetes, or the development of uncontrolled hypertension,or if there is the intercurrent development of a malignancy, the patientshould not receive the second dose.

Second injections under this protocol will be staggered so that singleinjections in different patients occur no less than 3 weeks apart. TheDSMB will review the clinical data regarding each of the first 3 secondinjections under this protocol, and will consult with the Sponsor beforethe 2^(nd), 3^(rd), and 4^(th) second injections are made. Subsequentsecond injections will continue to be staggered so as to occur no lessthan 3 weeks apart, but individual DMSB review will not be required.

No staggering will be required for first NKA injections under thisprotocol.

Post-Injection Follow-Up:

Subjects will return to the clinic for follow-up safety assessments onDays 7, 14, and 28 post-injection and at 2, 3, and 6 monthspost-injection. At 6 months post-injection, post-treatment MRI and renalscintigraphy studies will be conducted. After patients complete the 6month efficacy visit, they will be considered for a second NKAinjection. Patients receiving a second dose will follow the same followup visits that occurred after first injection. Patients 6 month postfirst injection visit will serve as the patients 14 to 10 day pre-secondinjection visit. Patients will return for their second injection andreturn to the clinic for follow up safety assessments on Days 7, 14, and28 post-injection and at 2, 3, and 6 months post-injection Patients willbe followed up to 18 months in the post follow up phase with 6 monthsafter first NKA injection and 12 months after second NKA injection.Refer to the time and events schedule on page 14 for additional postfollow up time points.

Long Term Follow-up:

Patients will be followed for safety and efficacy for 24 months afterthe 18 month initial follow up period. Telephone contact will be made 24and 36 months after the last NKA injection, and visits will be made at30 and 42 months after the last NKA injection.

NKA Dose:

Kidney weight of the target/recipient kidney will be estimated from theresults of the MRI taken during Screening. Using the preclinical studiesas a guideline, the dose of NKA for this study is 3×10⁶ cells/gestimated kidney weight (g KW^(est)). Since the concentration of SRC permL of NKA is 100×10⁶ cells/mL, the dosing volume would be 3 mL for each100 g or 6 mL for a 200 g kidney. Based on this dosing paradigm, thefollowing doses of NKA would be administered (Table 4):

TABLE 4 Estimated Kidney Weight (g KW^(est)) Dose SRC Delivered MedianWeight Weight Range Volume (cell number; (g) (g) (mL) ×106) 100  95-1083 300 117 109-125 3.5 350 133 126-141 4 400 150 142-158 4.5 450 167159-175 5 500 183 176-191 5.5 550 200 192-208 6 600 217 209-225 6.5 650233 226-241 7 700 250 242-258 7.5 750 >259 8 800

Safety Monitoring:

While unforeseen adverse effects may occur, the greatest recognized riskto subjects enrolled into the study is hemorrhage following theinjection procedure. Therefore, precautions have been taken to minimizethe risk of excessive bleeding. Patients with abnormal laboratory valuespredictive of an increased risk of bleeding will not be eligible for thestudy. Hemoglobin/hematocrit will be monitored a) before, b) 4 hoursafter, and c) the day after each procedure.

Injection:

During the injection procedure, hemoglobin will be monitored on aregular basis and blood pressure will be monitored continuously usingstandard site practices. Immediately following laparoscopic injection,the subject will remain supine for 8 hours with regular monitoring ofblood pressure/pulse and hemoglobin. The subject will remain in thehospital for 2 to 4 nights following laparoscopic injection forobservation of adverse events. On Day 1 following injection, anultrasound study will be performed to verify there are no subclinicaladverse effects. If clinically warranted, an ultrasound may also beperformed before discharge from the clinic to ensure no adverse eventsare ongoing. After an injection via the percutaneous route, the patientmay be discharged the same day if that is the site's usual practiceafter similar procedures (i.e. percutaneous ablation), after no lessthan 2 hours of observation and monitoring. If product- orprocedure-related AE's occurred following surgery, the patient shouldnot be released from the hospital until the AE's have either resolved,stabilized, or returned to baseline. After a laparoscopic injection, thepatient should be observed in hospital for 2 to 4 nights to assess forAEs. Following discharge, subjects will be monitored at each visit forchanges in renal function including the rate of progression of renalinsufficiency. Laboratory values predictive of renal function will beclosely monitored. Additional imaging studies may be conducted as neededin response to adverse changes in renal function.

Analysis Methods:

Up to 30 subjects will be injected with NKA. As this is a Phase IIsafety and early efficacy study, formal sample size calculations werenot performed. The planned sample size allows for a preliminarycharacterization of both the safety profile and potential efficacy ofthe administered dose of NKA in patients with chronic kidney disease.Subgroup analyses will compare patients receiving a single injectionwith patients receiving two injections, and patients receivinglaparoscopic injections with patients receiving percutaneous injections.The safety profile will consist primarily of an evaluation of adverseevents, including events of special interest, laboratory parameters,including assessments of renal function, imaging results and vitalsigns. An overview of the study flow is shown in the FIG. 8.

Laboratory Assessments

Laboratory assessments are listed below in Table 5. Laboratory resultswill be graded using the NCI CTCAE grading scale.

TABLE 5 Laboratory Assessments Chemistry Hematology Standard PanelHemoglobin—Hb Alanine Aminotransferase: Hematocrit—HCT ALT PlateletsAlkaline Phosphatase: ALP RBC Count Aspartate Aminotransferase: WBCCount AST WBC Differential Bilirubin Coagulation Status Creatine Kinase:CK Activated Partial Thromboplastin Gamma-glutamyl Transferase: Time:APTT GGT INR Lactate Dehydrogenase: LDH Urine Chemistry Renal AnalytesProtein & Albumin Albumin, serum Creatinine Calcium, serum Protein &Albunnin:Creatinine CO2, total Ratio (PCR & ACR) Creatinine, serumNeutroPhase 1l Gelatinase- Cystatin-C associated Lipocalin(NGAL) CReactive Protein: CRP Routine Urinalysis: UA* Glucose, serum AdditionalSelected Analytes Phosphorus, serum β2-Microglobulin, serum & urinePotassium, serum Hemoglobin (Hb) A1c Sodium, serum (intact) Parathyroidhormone; PTH BUN Virology Lipid Panel HIV-1, HBV, HCV CholesterolResearch (Reserve) Analytes LDL Serum/plasma and urine sample HDLExample: Fibroblast Growth LDL:HDL ratio Factor 23, Pentaxin 3Triglycerides Pregnancy (urine) *Routine UA using a urine test strip(dipstick). Microscopic analysis should only be performed if albumin,leukocytes, erythrocytes, or nitrites are positive.

eGFR:

For comparison of all subjects across the study, GFR will be estimatedusing the CKD-EPI equation. For comparison to each subject's historicalvalues, it may be necessary to perform a second analysis at the sitelaboratory used to generate the historical data.

Virology:

The biopsy samples collected from the patients will be used forselection of SRC and manufacture of NKA. Therefore, the patient will betested for viral blood-borne pathogens including HIV, HBV, and HCV.

Urine Chemistry:

Over the course of the study, urine will be collected over two differenttime periods; 24 hour collection and spot urine. Spot urine collectionswill be used for urine dipstick (test stick) assessments. The times forcollection of each type of sample are illustrated in the Time and EventsSchedule: Laboratory Assessments. To provide a comprehensive picture ofprotein and albumin excretion, both total protein and albumin should beassessed in all samples as appropriate for that type of sample.

Research (Reserve) Analytes:

Additional urine and serum/plasma samples will be collected, aliquotted,and stored for analysis of renal specific analytes and/or biomarkers ofrenal disease at a future time point. Potential analytes includefibroblast growth factor 23 (FGF23) and pentaxin 3 (PTX3).

Results from these analyses will not be available, nor will they beincluded in the Clinical Study Report (CSR) for this study.

Pregnancy:

A urine pregnancy test will be performed at the site using a test-strip.If the test is positive, then a confirmatory test will be performed atthe clinical laboratory. If site practices do not accept the results ofa test-strip, then a urine sample should be sent to the centrallaboratory for analysis.

Renal Imaging

Ultrasound

Ultrasound will be performed according to standard site procedures andwill be used to assess safety during injection, prior to and followinginjection. An ultrasound may be conducted at other times if required forsafety assessment or guidance of instrumentation during procedures.Findings from the ultrasound (e.g., resistance index, length, etc.) willbe recorded on the CRF.

Magnetic Resonance Imaging

MR imaging will be performed according to site standard practices.During the site initiation visit, the MRI process will be defined foreach site as dependent upon the MRI equipment in use. Generally, a 1.5-Tunit should be used. Images will be used to determine kidney volume (fordosing calculations) and may be used to measure renal corticalthickness. MRI will be performed using standard sequences withoutinjection of contrast agents. Volume measurements may be calculated, forexample, using a fast 3D gradient-echo sequence, VIBE, with anacquisition time of 22 sec. and spatial resolution of 2×1.4×1.2 mm. Theimaging parameters may be adjusted between patients; but the sameparameters must be used for before and after images on any one patient.The specific parameters used will be recorded in the source documentsand appropriate fields completed in the CRF.

Renal Scintigraphy

Renal scintigraphy has been used for a long time to measure relativekidney function. Historically, the method was performed with differentradiopharmaceuticals such as dimercaptosuccinic acid labeled withTechnetium-99m (99mTc-DMSA), diethylenetriamine pentaacetic acid(99mTc-DTPA), mercaptoacetyltriglycine (99mTc-MAG3), ethylenedicysteine(99mTc-EC) and orthoiodohippurate labeled with 1314 (131J-OIH). Amongthese, 99mTc-DMSA, a static renal agent, is considered as the mostreliable method to measure relative renal function and is the preferredagent for this study.

Renal scintigraphy using 99mTc-DMSA is being advocated as the preferredmethod for assessment of renal function following several types ofkidney disease. Its uptake correlates with effective renal plasma flow,glomerular filtration rate and creatinine clearance. Its quantitativemeasurement is therefore a good index for relative renal function.Previous studies have shown that 99mTc-DMSA uptake differentiates normalfrom diseased kidney. If the site routinely uses a different agent, thenthe method should be reviewed at the site initiation visit.

The site should use their standard site procedure. Outline of an exampleprocedure is below:

-   -   Patient should receive an intravenous injection of 50 MBq        99mTc-DMSA with imaging performed 3 hours after injection.    -   Patient will be placed in supine position and an acquisition of        posterior view with preset time of 15 minutes, 256×256 matrix        will be performed with ultra-high resolution collimator.    -   Differential renal function will be calculated using        region-of-interest drawings.

Surgical Procedures

Biopsy

The biopsy should be collected from the left/right kidney under sterileconditions using an ultrasound or CT guided method as dictated by sitestandard practices. The only difference from the standard procedure maybe collection of 2 tissue cores and use of a 16 gauge needle. Two biopsyrenal tissue cores are needed to insure sufficient cortical tissue iscollected for selection of SRC and manufacture of NKA. Likewise, a 16gauge biopsy needle should be used to insure sufficient corticalmaterial is collected for manufacture of NKA. If site standard practicesdictate use of a 15 gauge biopsy needle, then a 15 gauge needle may beused following consultation with the Medical Monitor. In any case, it isimperative that as much cortical tissue is collected as possible. Ifavailable at the site, bedside examination of the biopsy cores may beperformed to ensure sufficient cortical material is obtained.

It is important to remember that the biopsy tissue will be used tomanufacture NKA, an injectable product. Therefore, the site shouldensure that individuals collecting the biopsy are aware that the tissuecores must be harvested using sterile conditions so that the risk ofcontamination during cell expansion and selection is minimized.

Guidance on wound care and pain management following the injectionprocedure will be provided in the Study Reference Manual. Importantly,pain medication administered to the patient post-biopsy should selectedcarefully, avoiding as possible medications with nephrotoxic potential.Specialized patient care surrounding the injection will focus onminimizing potential bleeding events. The subject will remain supine for4 hours with monitoring of hemoglobin, blood pressure, gross hematuria,abdominal/flank pain, and flank ecchymosis. In addition, the patient maybe discharged the day of biopsy per site standard practice. If a subjectexperiences significant adverse events following the biopsy that, in theopinion of the PI would put the subject at increased risk forsignificant adverse effects following biopsy, then he/she will not beinjected with NKA, but will be followed until resolution of the event(s)and then discontinued from the study.

Injection

NKA prepared in a sterile syringe and transported to the surgical suitewill be equilibrated to 26.5±1.5° C. for a minimum of 30 minutes but notmore than 120 minutes immediately prior to injection into the patient.

Patients will be injected with NKA using either: (1) a percutaneousminimally-invasive image-guided direct-needle approach, or (2) alaparoscopic technique similar to that used to deliver NKA in the caninestudies and already utilized 6 or more times in the Swedish study inhumans. The objective in either case is to approach at an angle allowingdeposition of NKA in the renal cortex, distributed as widely asfeasible. This could require imaging the kidney in a longitudinal ortransverse approach, depending upon individual patient characteristics.Ideally the injection will involve multiple deposits as the injectionneedle/cannula is gradually withdrawn. The volume to be injected isdetermined by the weight of the kidney as estimated from the MRI, up toa maximum of 8 mL. For an 8 mL injection, it is anticipated that one totwo mL will be deposited in 8 to 4 increments, respectively. Up to twoentry points may be used to deposit the full volume of NKA into thekidney (two entry points per kidney were routinely used in all of theanimal studies). NKA must be administered slowly at a rate no fasterthan 2 mL/min, ensuring viability of the NKA. If possible, the injectionprocedure will be viewed by the sponsor and actual injection of thekidney will be recorded on video for use as an educational/trainingtool. Prior to surgery, the site must document the specific proceduralapproach that will be used to access the kidney.

Percutaneous Procedure:

Prior to the procedure, the operating physician will evaluate thepatient, including:

-   -   a. Physical evaluation, to determine the feasibility of the        procedure in general;    -   b. Evaluation of bleeding parameters, including coagulation        panel, INR, platelets, hemoglobin, hematocrit, and other        pertinent laboratory studies as indicates;    -   c. Review of available imaging studies, including ultrasound,        MRI, and/or CT, to determine route of access, depth of kidney,        and appearance of cortical-medullary junction. Mapping of        potential sites of NKA cell deposition will be performed.    -   d. Determination of ASA class from airway assessment, medical        history, allergies, and medications.    -   e. Interview of patient and family/supporters to discuss the        procedure, its risks and possible complications, sedation,        answer questions, and obtain documented informed consent.

Procedural technique: Specifically, a co-axial technique will beutilized (details below).

Image guidance: The operator will determine which kidney was biopsied,and will plan his approach to that kidney via longitudinal, transverse,or both reference planes. Imaging options during the procedure includeultrasound alone or ultrasound with complementary CT; the operator willverify and document the availability of adequate functionality,including color Doppler, measuring ability, probe frequency, and overalldesign.

Prior to the procedure, abnormal coagulation values will be corrected.Prophylactic antibiotics will be given intravenously according to theusual practices at the site. An initial CT scan may be ordered ifnecessary, for evaluation of adjacent viscera, renal location, presenceof renal cysts, and for determination of the cortical-medullary junctionin conjunction with ultrasound. During the procedure, moderate conscioussedation will be employed, and patient monitoring will be continuous.

NKA is targeted for injection into the kidney cortex via a needle(cannula) compatible with cells. The intent is to introduce NKA viapenetration of the kidney capsule and deposit into multiple sites of thekidney cortex. Initially, the kidney capsule will be pierced using a15-20 gauge access trocar/cannula inserted approximately 1 cm into thekidney cortex (but not advanced further into the kidney). NKA iscontained in a syringe that will be attached to a blunt tipped innerneedle or flexible cannula (18-26 gauge, as suitable for the accesscannula). In the Phase 1 clinical study, NKA was delivered via an 18Gneedle. The proposed Phase II study will utilize an 18 gauge or smallerneedle (18-26 gauge) for NKA injection. The needle will be threadedinside the access cannula and advanced into the kidney, from which theNKA will be administered. Injection of the NKA will be at a rate of 1-2ml/min. After each 1-2 minute injection, the inner needle will beretracted along the needle course within the cortex to the second siteof injection; and so forth until the needle tip is at the end of theaccess cannula or the entire cell volume has been injected. Thisprocedure can be used for both laparoscopic (used previously in Phase Istudy) and percutaneous injection of NKA. For percutaneous injection ofNKA, the placement of the access cannula/trocar and needle will beperformed using direct, real-time image guidance. Injection of the NKAwill be monitored with ultrasound image guidance to visualize themicrobubble footprint of cell deposits.

NKA injection will cease if there is imaging evidence of cellextravasation into central or peripheral renal blood vessels, themedullary portion of the kidney, or through the renal cortex and intothe retroperitoneal soft tissues, or evidence of active bleeding. Atthis point, the needles are withdrawn. Additional renal injection sitesmay be chosen if NKA remains to be injected, along the same needletrack, or at a new site in a different location in the kidney.

Following completion of NKA injection, the inner needle will bewithdrawn and the outer cannula will remain in place for trackembolization. During removal of the outer cannula (trocar), the site ofthe renal cortex puncture and needle track through the retroperitoneumwill be embolized with absorbable gelatin particle/pledgets (e.g.Gelfoam [Pfizer]) or fibrin sealant (e.g. Tisseel [Baxter]) or othersuitable agent to prevent renal bleeding.

At completion of the procedure, non-contrast CT scan or ultrasound withcolor Doppler evaluation will be performed to assess for puncture sitecell injection and any hematoma or bleeding. For 2 to 3 hourspost-procedure there will be observation in a recovery-room environmentwith nursing assessment and vital-sign monitoring. The patient may bedischarged after that, if all indices are normal. A follow-up phone callwill be conducted at 24 hours post-discharge, and follow-up in clinicwill continue per protocol.

Minimally-Invasive Laparoscopic Procedure:

Using the second method, the kidney will be accessed while the patientis under full anesthesia, using a robotic- or hand-assisted laparoscopicapproach. (The site may choose to use HARS as described in Wadstrom etal., 2011a and 2011b, or else a standard robotically-assisted method).Using a robotic- or hand-assisted approach allows the surgeon to placethe kidney in an optimal position for the injection. It also allows thesurgeon to visualize and stop bleeding if this should occur. Bloodpressure will be monitored continuously during surgery using standardsite surgical practices.

Once the kidney is accessed, NKA will be injected at an angle thatallows for deposition of NKA into the kidney cortex. The cannula shouldbe inserted to a depth that allows for multiple depositions of NKA asthe cannula is retracted from the kidney. Entry points should be off themid line of the kidney and angled to maximize deposition of NKA intokidney cortex.

Immediately after injection, the patient will recover in apost-operative surgical recovery unit under supervision. The patientwill not be taken to his/her room until all vital signs are stable.Overall, the patient will be kept in the bed for at least 8 hours withmonitoring of blood pressure and pulse. The patient should be closelymonitored for 24 hours by a skilled team of caregivers used to dealingwith post-operative problems. If pain, fever, dramatic decreases inblood pressure/hemoglobin, or any other clinical sign/symptom indicatespotential adverse reactions/events, then further physical examinations(potentially including x-rays or ultrasound investigations) must becarried out liberally and swiftly for diagnostic purposes.

In addition to standard safety measures, hemoglobin will be monitoredbefore, 4 hours after, and then daily while hospitalized followinginjection. Patients will remain in the hospital for 2 to 4 nightsfollowing surgery. Patients will not be released from the hospital untilprocedure- and/or product-related AE's have resolved, stabilized, orreturned to baseline.

Post-procedure Evaluation of the injection: With either procedure, ifNKA leaks from the kidney during deposition, then the amount leakedshould be estimated and recorded in the CRF. To prevent further leakage,the rate of injection may be slowed. As part of this protocol, injectionparameters including (but not limited to) rate of injection and angle ofinjection may be adjusted for optimization.

Initial Results—Phase II, Open Label Safety and Efficacy Study of anAutologous NKA in Patients with Type 2 Diabetes and Chronic KidneyDisease (RMCL-001)

Patients received a 1st injection of NKA under clinical protocolTNG-CL011 (NCT02008851) and a 2nd injection of NKA approximately 2.5years later under clinical protocol RMCL-CL001 (NCT02525263).

Clinical Outcomes demonstrated that in 4 of 7 patients remained dialysisfree for ˜4 years with stabile renal function. Pre-Implantation declinein eGFR for patient cohort was −6.1 ml/min/1.73 m3*(Red-line). (FIG. 9)NKA reduced decline in eGFR after 1 year post-implantation to −3ml/min/1.73 m3 (Green-line). Range of kidney function decline in CKDpatients and onset of dialysis (Blue zone). In summary, Populationtreated: patients (n=7) with pre-dialysis CKD stage 3B/4. All trialpatients are commercially relevant population and served as their owncontrols. Pre-implantation mean eGFR=22 ml/min/1.73 m3 (CKD4). Nopatients had product-related adverse events. No patient received fulltherapeutic dose in both kidneys, just a single dose in a single kidney.

Representative metabolic measures for a patient is provided in Table 6.

TABLE 6 Height Weight Serum Date Visit (cm) (kg) Creatinine Cystatin CCKDEPI MDRD Jul. 16, 2016 Screen 170.2 120.3 5.95 3.7 15 16 Cm Jul. 20,2016 Re-Screen 115.9 4.95 18 19 Jul. 28, 2016 Day −14 to −10 115.9 5.0517 19 Aug. 9, 2016 Day 0  113 6.55 13 14 Aug. 15, 2016 Day 7  112.8 7.683.9 10 11 Aug. 19, 2016 Day 14 114.2 5.83 3.49 15 16 Sep. 7, 2016 Day 28112.2 5.16 3.2 17 18 Oct. 6, 2016 Month 2 111.1 5.79 14 16 Nov. 4, 2016Month 3 111.6 6.25 4.02 18 20 Feb. 7, 2017 Month 6 114.6 7.72 3.91 14 16Mar. 17, 2017 Unscheduled 6.47 11 Apr. 7, 2017 End of Study

Prior to the first NKA injection, this patient suffering from Type 2Diabetes and Chronic Kidney Disease had a rate of eGFR decline of6/ml/min/yr. In this patient, the pre-NKA injection—CKD 4 eGFR ˜20ml/min. After receiving a first NKA injection, the rate of eGFR declinewas reduced to approximately 50% to 3/ml/min/yr over a 2.5 year period(FIG. 10A). After receiving the 2nd NKA injection, the eGFR increased byapproximately 50% three months post-injection, stabilized in thefollowing 6 months of observation and rescued the patient for 8 monthsof dialysis-free life (FIG. 10B).

The reduced rate of eGFR decline, indicative of glomerular filtrationrate, suggests that patients treated with NKA (also referred to asAdvanced Cell Therapy (ACT)) had slower rates of kidney functiondecline. Just a single low dose allowed their kidneys to filter bloodmore effectively (FIG. 11). Furthermore, ACT is a therapy forco-morbidities. Patients treated with ACT were able to reduce bloodpressure medication because better kidney function supports bettermetabolic and endocrine function (FIG. 12).

Overall, this data strongly supports the efficacy of re-injectingpatients with a second NKA injection. It may also suggest re-dosing 3months after the first dose to ensure durable impact on kidney function.Dosing both kidneys or having the ability to do multiple doses (i.e. >2)in the same kidney may further increase kidney function.

Example 3—NKA Injection for Interventional Radiology

Clinic Evaluation:

For clinical evaluation prior to procedure, it is recommended to ensureadequate renal visualization, renal axis, and kidney size, presence ofrenal masses/cysts/para-pelvic cysts, renal cortex thickness and depthof kidneys from skin surface.

NKA Delivery

Cell Suspension:

Volume to be determined by pre-procedure MRI volumetric 3D evaluation.

Needle Size and Placement:

18 gauge (ga) diamond tip needle inserted with ultrasound(US)/computerized tomography (CT) scan guidance and needle tip advancedbeneath the capsule 5-10 mm into the renal parenchyma. A 21-27 ga innerneedle is advanced through outer needle into the subcapsular renalparenchyma approximately 4-5 cm distal to the tip of the trocar needleor until the tip reaches the more distal portion of the far renalsubcortical tissue. Advance needle as new the subcortical capsules aspossible but avoid capsule perforation.

Needle placement may encounter the lateral/medial cortex contour, andmay shortening or lengthening the cell delivery depth in thecortical/subcapsular location. Ideal delivery site via the transverseplane will be in the mid to lower pole location. Needle advancement isdone with US guidance to ensure proper placement and confirmed ifnecessary with axial CT imaging.

Initial and final needle placement is confirmed with US/CT imaging andrecorded. The distance from the lower pole to the needle entrance siteis measured and recorded. (See FIGS. 13-15)

NKA Cell Injection:

The cell solution will be delivered by the study coordinator inconjunction with the preparation research pharmacy, in with apredetermined volume in a 10 ml syringe. If sterile then the syringe canbe passed to the IR operator. If nonsterile, then transfer the NKA frompreparation syringe to a sterile syringe. A connector tube is insertedbetween the syringe and needle hubs in order to allow for injectionflexibility.

The needle is withdrawn 1 cm from original tip position and the stemcell injection started, injecting up to 2 ml of cell solution at therate of 1-2 ml of cell slurry per minute under US guidance observing forechogenic dispersion of the slurry into the renal cortex tissue. A timeris recommended to monitor injection rate. The injection is then stoppedand the needle withdrawn another 1 cm, followed by the second injectionof up to 2 ml of cell solution. This is repeated for up to a total of 4injections of up to 8 ml of cell solution. If the renal parenchyma doesnot accommodate a 4 cm injection length then the injections are stoppedat the length and corresponding volume that the renal size allows. Donot inject more than 8 ml per needle puncture. At conclusion of theneedle injection place small (2-4 mm diameter×10 mm length) gelfoam(Gelatin sponge, Pfizer) plug into the needle before withdrawal fromneedle.

If injection volumes are limited due to needle penetration into thecortex, obstruction or other constraints such that the total cellsolution volume injected is less than the required injection volumebased on renal size, a second renal puncture will be necessary tocontinue or finish the NKA delivery. Careful observation of needlewithdrawal and stable position of trocar needle may require an assistantto manage US imaging and stabilize trocar needle. If incomplete deliveryobtained with initial needle placement then second or third injectionsite will be chosen.

Under US/CT guidance, a second puncture is made with the 18 gauge trocarneedle into a second location at least 2 cm superior or inferior to thefirst delivery site. The injection site may me along the same renalmargin or the opposite side. The needle placement, US/CT needle tipconfirmation, and injection method is repeated in a similar manner.

Masses:

Renal cysts are avoided. If necessary, aspirate renal cyst (s) to avoidinjection and collection of cells into the cyst if no other access siteis available. Solid masses are avoided and solid renal mass workupinitiated to include MRI or CT imaging and possible biopsy. Solid massesshould be excluded prior to injection unless there is a delay betweenNKA preparation and injection and a new mass appears.

Injection Rate Time:

1-2 millimeter of cell solution per minute under US observation.

CT scan without contrast: CT scan with 5 mm thick axial slices anddiagnostic quality mA from lower liver through the kidneys withlocalization grid placed over kidney to be injected. Select posterior orposterior-lateral approach avoiding other structures in the mid to lowerpole region. Patient positioned prone or decubitus if necessary.

Sedation:

Moderate conscious sedation. General anesthesia for certain situationsto include ASA 4,5, difficult airway, patient request, inability toposition, heart/lung/liver comorbidities or other increased anesthesiarisk situations.

CT or US Guidance:

Needle placement along longest transverse axis from posterior or lateralby CT or US guidance of from longitudinal direction if able to addressapproach angle. Cell delivery to be observed with US in order toidentify microbubble tract as needle is withdrawn. Length and rate ofdelivery into the kidney will determine the amount of cell slurryinjected.

Final CT and US to be done after withdrawal to evaluate for bleeding,injection site complications to kidney and adjacent organs.

Example 4—A Phase II, Open-Label Safety and Tolerability Study of anAutologous Neo-Kidney Augment (NKA) in Patients with Type 2 Diabetes andChronic Kidney Disease (RMCL-002 and RMCL-003)

A regenerative cell-based product, Neo-Kidney Augment (NKA), has beendeveloped with the aim of improving renal function in subjects who haveCKD and T2DM. As noted above, therapeutic intervention with NKA isintended to delay the need for renal replacement therapy (dialysis ortransplant) which, based on the current standard-of-care, is inevitablefor patients with end-stage CKD. The purpose of the present study is tocompare the safety and efficacy of up to 2 injections of NKA given 3months (+12 weeks) apart (maximum) in subjects who are randomized toreceive their first treatment as soon as the NKA product is madeavailable versus subjects who are randomized to undergo contemporaneous,standard-of-care treatment for CKD during the first 12-18 months priorto receiving up to 2 injections of NKA. In addition, each subject'sannual rate of renal decline, based on adequate historical, clinicaldata from 18 months prior to the Screening Visit, will serve as acomparator to monitor the rate of progression of renal insufficiencypre- and post-randomization.

We propose that NKA treatment will reduce the rate (slope) of eGFRdecline and improve renal function over the 24 month period followingthe last NKA injection.

Study Objectives:

Primary Objective:

The primary objective of the study is to assess the safety of NKAinjected in one recipient kidney.

-   -   Primary Outcome/Endpoint Measures: procedure and/or product        related adverse events (AEs) through 24 months post-injection.

Secondary Objective:

The secondary objective of the study is to assess the safety andtolerability of NKA administration by assessing renal-specific adverseevents over a 24 month period following injection.

-   -   Secondary Outcome/Endpoint Measures: renal-specific laboratory        assessments through 24 months post-injection.

Exploratory Objective:

Exploratory objectives of the study are designed to assess the impact ofNKA on renal function over a 24 month period following injection.

-   -   Exploratory Outcome/Endpoint Measures: clinical diagnostic and        laboratory assessments of renal structure and function        (including eGFR, serum creatinine, and proteinuria) to assess        changes in the rate of progression of renal disease.

Study Design:

Multi-center, prospective, open-label, single-group study. All subjectswill be treated with two NKA injections 3 months (+12 weeks) apart afterbiopsy.

Randomization:

Open-Label, Non-Randomized.

Control Group:

Each subject will serve as his or her own control; the patient'sprevious medical history, which must include a minimum 6 month period ofobservation of renal function, will serve as the control for rate ofprogression of renal insufficiency.

Sample Size:

Up to 10 patients will be treated with NKA. As this is a Phase II safetystudy, robust statistical analysis will not be performed. Therefore, thesample size proposed for this study is a size typical for in Phase 1studies, allowing for identification of safety outcomes in a limitedpopulation.

Study Population:

Male or female patients 30 to 85 years of age with CKD and eGFR between14 and 20 mL/min/1.73 m². Patients should have sufficient historicalclinical data to determine their individual rate of CKD diseaseprogression.

Inclusion Criteria:

Unless otherwise noted, subjects must satisfy each inclusion criterionto participate in the study. Inclusion criteria will be assessed at theScreening Visit, prior to renal biopsy, and before each NKA injectionunless otherwise specified.

-   -   1. The subject is male or female, 30 to 85 years of age on the        date of informed consent.    -   2. The subject has an established diagnosis of T2DM.    -   3. The subject has an established diagnosis of diabetic        nephropathy as the underlying cause of renal disease.    -   4. The subject has an established diagnosis of CKD not requiring        renal dialysis, defined as having an eGFR between 14 and 20        mL/min/1.73 m² inclusive at the Screening Visit and prior to NKA        injection.    -   5. The subject has urine albumin excretion greater than or equal        to 30 mg/day.    -   6. The subject has blood pressure less than 140/90 at the        Screening Visit, prior to renal biopsy, and prior to NKA        injection(s). Note BP should not be significantly below 115/70.    -   7. The subject has stable blood pressure or has ongoing and        stable treatment with an angiotensin-converting-enzyme inhibitor        (ACEI) or an angiotensin receptor blocker (ARB) initiated at        least 8 weeks prior to renal biopsy. Treatment must be stable        during the 6 week period immediately prior to NKA injection.        Stable treatment is defined as dose adjustment no less than one        half of the current dosage and no more than 2 times the current        dosage. Dose interruptions up to 7 days due to medical necessity        are allowed. A subject who is intolerant to ACEI or ARBs may be        included as long as he/she has stable blood pressure within the        specified limits.    -   8. A minimum of 2 measurements of eGFR or sCr should be obtained        at least 3 months apart prior to the Screening Visit or within        the previous 18 months to define the rate of progression of CKD.        The subject should have adequate, historical clinical data to        provide a reasonable estimate of the rate of progression of CKD        following consultation with the Medical Monitor (to ensure that        there are sufficient data).    -   9. The subject is willing and able to refrain from NSAID        consumption (including aspirin) as well as clopidogrel,        prasugrel, or other platelet inhibitors during the period        beginning 7 days before through 7 days after both the renal        biopsy and NKA injection(s).    -   10. The subject is willing and able to refrain from consumption        of fish oil and platelet aggregation inhibitors, such as        dipryridamole (ie, Persantine®), during the period beginning 7        days before through 7 days after both the renal biopsy and NKA        injection(s).    -   11. The subject is willing and able to cooperate with all        aspects of the protocol.    -   12. The subject is willing and able to provide signed informed        consent.

Exclusion Criteria:

Subjects who satisfy any exclusion criterion listed below are noteligible to participate in the study. Exclusion criteria will beassessed at the Screening Visit, before renal biopsy, and before eachNKA injection unless otherwise noted.

-   -   1. The subject has a history of type 1 diabetes mellitus.    -   2. The subject has a history of renal transplantation.    -   3. The subject has a serum HbA1c level greater than 10% at the        Screening Visit.    -   4. The subject has uncontrolled diabetes (defined as        metabolically unstable by the Investigator).    -   5. The subject has hemoglobin levels less than 9 g/dL prior to        each NKA injection.    -   6. The subject has abnormal coagulation status as measured by        activated partial thromboplastin time (APTT), prothrombin time        international normalized ratio (PT INR), and/or platelet count        at the Screening Visit.    -   7. The subject has a bleeding disorder(s) or is taking        anticoagulants, such as Coumadin® (warfarin) or direct thrombin        inhibitors that, in the judgment of the Investigator, would        interfere with the performance of study procedures.    -   8. The subject has small kidneys (average size less than 9 cm)        or has only one kidney, as assessed by ultrasound and/or MRI        prior to renal biopsy, unless earlier radiology reports        (generated within 1 year of the Screening Visit) are made        available to confirm kidney size and number.    -   9. The subject has a known allergy or contraindication(s), or        has experienced severe systemic reaction(s) to kanamycin or        structurally similar aminoglycoside antibiotic(s)    -   10. The subject has a history of anaphylactic or severe systemic        reaction(s) or contraindication(s) to human blood products or        materials of animal origin (eg, bovine, porcine).    -   11. The subject is not a good candidate to undergo percutaneous        NKA injection, in the judgment of the surgeon or physician who        will perform the procedure. This includes individuals who are        morbidly obese (defined as BMI greater than 45 kg/m2), have        excessive fat surrounding the kidney, or who are otherwise at        excessive risk for serious complications.    -   12. The subject has a history of severe systemic reaction(s) or        any contraindication to local anesthetics or sedatives.    -   13. The subject has a clinically significant infection requiring        parenteral antibiotics within 6 weeks of NKA injection.    -   14. The subject has acute kidney injury or has experienced a        rapid decline in renal function during the last 3 months prior        to NKA injection.    -   15. The subject has any of the following conditions prior to NKA        injection: renal tumors, polycystic kidney disease, anatomic        abnormalities that would interfere with the NKA injection        procedure or evidence of a urinary tract infection.    -   16. The subject has incapacitating cardiac and/or pulmonary        disorders.    -   17. The subject has a history of cancer within the past 3 years        (excluding non-melanoma skin cancer and carcinoma in situ of the        cervix).    -   18. The subject has clinically significant hepatic disease (ALT        or AST greater than 3 times the upper limit of normal) as        assessed at the Screening Visit.    -   19. The subject is positive for active infection with Hepatitis        B Virus (HBV), or Hepatitis C Virus (HCV), and/or Human        Immunodeficiency Virus (HIV) as assessed at the Screening Visit.    -   20. The subject has a history of active tuberculosis (TB)        requiring treatment within the past 3 years.    -   21. The subject is immunocompromised or is receiving        immunosuppressive agents, including individuals treated for        chronic glomerulonephritis within 3 months of NKA injection.    -   Note: inhaled corticosteroids and chronic low-dose        corticosteroids (less than or equal to 7.5 mg per day) are        permitted as are brief pulsed corticosteroids for intermittent        symptoms (eg, asthma).    -   22. The subject has a life expectancy less than 2 years.    -   23. The female subject is pregnant, lactating (breast feeding),        or planning a pregnancy during the course of the study. Or, the        female subject is of child-bearing potential and is not using a        highly effective method(s) of birth control, including sexual        abstinence. Or, the female subject is unwilling to continue        using a highly-effective method of birth control throughout the        duration of the study.    -   Note: A highly effective method of birth control is defined as        one that results in a low failure rate (ie, less than one        percent per year) when used consistently and correctly, such as        implants, injectables, combined oral contraceptives, some        intrauterine devices IUDs, sexual abstinence, or a vasectomized        partner.    -   24. The subject has a history of active alcohol and/or drug        abuse that, in the judgment of the Investigator, would impair        the subject's ability to comply with the protocol.    -   25. The subject's health status would, in the judgment of the        Investigator, be jeopardized by participating in the study.    -   26. The subject has used an investigational product within 3        months prior to NKA injection without receiving written consent        from the Medical Monitor.

Number of Sites:

Up to 5 clinical centers will be included in the study.

Study Duration:

Treatment to begin as soon as the NKA product is made available andassuming a one month interval prior to receiving the first NKAinjection, and assuming a 3 month interval before receiving the secondinjection, plus a 24 month follow up period after the final injection,the duration of treatment would be 28 months for a series of 2 NKAinjections.

Study Enrollment:

Up to 10 subjects will be enrolled into the study. Patients who completescreening procedures satisfying all TIE criteria will be enrolled intothe study immediately prior to the biopsy. Patients who do not meet allcriteria before the biopsy is taken will be considered screen failures.Patients who have a biopsy but are not injected for whatever reason willbe discontinued from the study and may be replaced. Once a patient hasbeen injected, the patient will have completed treatment and everyeffort should be made to ensure the patient completes all follow-upvisits.

Investigational Plan:

Screening:

Subjects who satisfy eligibility criteria and provide written informedconsent may be entered into the study. The subject should have adequate,historical clinical data to provide a reasonable estimate of the rate ofprogression of CKD following consultation with the Medical Monitor.Screening procedures include a full physical exam, ECG, and laboratoryassessments (hematology, clinical chemistry, and urinalysis). Anultrasound will be performed to confirm the presence of two kidneys withnormal anatomic features. A MRI study will determine kidney size andvolume.

Renal Biopsy:

Three days or less before undergoing renal biopsy, enrolled subjectswill report to the clinic and undergo an interim physical exam alongwith an ECG and renal MRI (if not completed during or after theScreening Visit). Laboratory tests, including renal function,hemoglobin, and a pregnancy test for females also will be performed.Eligible subjects satisfying all inclusions and exclusion criteria willbe admitted to the hospital/clinical research center to undergo a kidneybiopsy. A minimum of 2 tissue cores measuring at 1.5 cm a piece must becollected using a 16 gauge biopsy needle to provide sufficient materialfor the manufacture of NKA. Subjects who do not experience complicationsfrom the biopsy may be discharged the same day consistent with sitestandard practice.

NKA Injection:

Ten to 14 days before the scheduled injection date, subjects willundergo an interim physical exam for ongoing verification of inclusionand exclusion criteria. Subjects also will undergo renal scintigraphy(ie, split kidney function scan) to find out what percentage each kidneycontributes to total baseline kidney function. On the day of thescheduled NKA injection, eligible subjects will be admitted into thehospital/clinical research unit. After warming to liquefy the hydrogel,NKA will be injected into the same kidney that was previously biopsiedusing a percutaneous approach. This procedure will follow a standardizedtechnique, such as that used in the ablation of renal masses byradiofrequency or cryogenic methods. Subjects without complications maybe discharged the same day consistent with site standard practice. Anultrasound will be performed the day after injection to detect possible,subclinical AEs. It is anticipated that all subjects will receive 2 NKAinjections given 3 months (+12 weeks) apart. The first and secondinjections will occur in the same kidney in which the biopsy was taken.Therefore only one kidney will be used for the duration of this study.

Follow-Up:

Subjects will complete follow-up evaluations on Days 1, 7, 14, 28 (±3days) and Month 2 (±7 days) after the first and second NKA injections.Depending on when the second injection is administered (ie, at 3 months[+12 weeks]), subjects may undergo evaluations at 3 and 6 months afterthe first NKA injection. Following the final NKA injection, subjectswill complete long term, follow up assessments of safety and efficacythrough 6, 9, 12, 15, 18, 21, and 24 months post-treatment.

Safety Monitoring:

Hemorrhage following NKA injection is a known and foreseeable risk tosubjects participating in this study. Therefore, hemoglobin will bemeasured by the site's local laboratory at the following times: a)before, b) after procedure per site standard practice

Investigational Product, Dosage and Mode of Administration:

Investigational Product:

NKA is made from expanded autologous selected renal cells obtained fromeach individual subject's kidney biopsy. To manufacture NKA, biopsytissue from each enrolled subject will have renal cells expanded and SRCselected. SRC will be formulated in a gelatin based hydrogel at aconcentration of 100×10⁶ cells/mL, packaged in a 10 mL syringe, andshipped to the clinical site.

Dosage:

The volume of NKA to be administered will be determined by pre-procedureMRI volumetric 3D evaluation or ellipsoid formula (Length×width APplane×width Transverse plan×0.62). Based on pre-clinical data, the doseof NKA will be 3×10⁶ cells/g estimated kidney weight (g KW^(est)). Sincethe concentration of SRC per mL of NKA is 100×10⁶ cells/mL, the dosingvolume will be 3.0 mL for each 100 g of kidney weight. Using this dosingparadigm, the following table shows the dosing volume and number of SRCto be delivered relative to estimated kidney weight (Table 7). Themaximum volume of NKA injected into the biopsied kidney will be 8.0 mL.

TABLE 7 Estimated Kidney Weight (g KW^(est))* Dosing SRC DeliveredMedian Weight Weight Range Volume (Number of (g) (g) (mL) Cells ×10⁶)100  95 108 3.0 300 117 109-125 3.5 350 133 126-141 4.0 400 150 142-1584.5 450 167 159-175 5.0 500 183 176-191 5.5 550 200 192-208 6.0 600 217209-225 6.5 650 233 226-241 7.0 700 250 242-258 7.5 750 — >259 8.0 800*Kidney weight will be estimated from the results of an MRI studyperformed on or after the Screening Visit until Day 0 (renal biopsy).

It is anticipated that all subjects will receive two planned NKAinjections to allow dose-finding and evaluate the duration of effects.The first and second injections will occur in the same kidney in whichthe biopsy was taken. In some cases, a subject or the Investigator maydecide to postpone or withhold the second NKA injection. For example, ifthere appears to be any untoward safety risk, or rapid deterioration ofrenal function, or the development of uncontrolled diabetes oruncontrolled hypertension, or the development a malignancy or anintercurrent infection, then the second NKA injection should not beadministered.

Mode of Administration:

NKA will be injected into the biopsied kidney using a percutaneousapproach. The percutaneous method will employ a standardized technique(such as that utilized in the ablation of renal masses by radiofrequencyor cryogenic methods).

Statistical Analysis Methods:

Statistical analyses will be primarily descriptive in nature and nostatistical hypothesis testing is planned for the study. Unlessotherwise specified, continuous variables will be summarized bypresenting the number of non-missing observations (n), mean, standarddeviation, median, minimum, and maximum. Categorical variables will besummarized by presenting frequency count and percentage for eachcategory.

Rationale for Two NKA Injections

It is anticipated that all subjects will receive two planned NKAinjections to allow dose-finding and evaluate the duration of effects.The scientific rationale, based on non-clinical studies, is that thebiologically active component of NKA (homologous, autologous, SRC)delays progression of experimental models of CKD by augmenting renalstructure and function. (Bruce et al. Selected renal cells modulatedisease progression in rodent models of chronic kidney disease via NF-κBand TGF-β1 pathways. Regen Med. 2015; 10:815-39; Bruce et al. Exposureof cultured human renal cells induces mediators of cell migration andattachment and facilitates the repair of tubular cell monolayers invitro. Experimental Biology Meeting, Washington, D C, 2011; Atala et al.Tissue-engineered autologous bladders for patients needing cystoplasty.Lancet. 2006; 367:1241-46; Jayo et al. Long-term durability, tissueregeneration and neo-organ growth during skeletal maturation with aneo-bladder augmentation construct. Regen Med. 2008; 3:671-82; Jayo etal. Early cellular and stromal responses in regeneration versus repairof a mammalian bladder using autologous cell and biodegradable scaffoldtechnologies. J Urol. 2008; 180:392-7; Jayo et al. Tissue engineeringand regenerative medicine: role of toxicologic pathologists for anemerging medical technology. Toxicol Pathol. 2008; 36:92-6) As a result,the more cells that can be infused, the greater the potentialimprovement in renal function. The total number of cells that can bedelivered into a kidney at one time is limited by the size of thekidney, however, as well as the inelasticity of the renal capsule.Consequently, it may be possible to improve therapeutic benefit byadministering greater numbers of SRC via a second injection, given aftercells from the first injection have become incorporated into the kidney.

Apart from increasing SRC numbers by administering 2 NKA injections intothe same kidney, the duration of effects can be evaluated. The processesby which functional nephrons become disabled in kidneys with CKD may,over time, adversely affect “new” cells delivered via NKA injection.Consequently, NKA might not result in long-term, therapeutic benefit.Exploring the effects from a second NKA injection, given at anappropriate interval after the first injection, would address thisquestion.

In the present study, subjects will be administered a second NKAinjection 3 months after the first injection, with a study visit windowof 12 weeks. Regardless, every attempt should be made to ensure that thesecond NKA injection is administered 3 months after the first injection.However, if there appears to be any untoward safety risk, or rapiddeterioration of renal function, or development of uncontrolled diabetesor uncontrolled hypertension, or development of a malignancy or anintercurrent infection, then the second NKA injection should not beadministered.

Safety of Two NKA Injections

To assess the safety of administering two doses of NKA into the biopsiedkidney, a canine GLP toxicology study was conducted. Similar to theclinical study design, study animals (n=8) underwent renal biopsies at 4to 6 weeks prior to baseline. Each dose was delivered into both kidneysat baseline and 3 months; animals were observed for 6 months followingthe baseline injection. While control animals received PBS, NKA-treatedanimals received a two-fold greater dose than that used in the presentclinical study.

Briefly, no detrimental effects of two doses of NKA into the biopsiedkidney were observed in comparison to control animals 6 months afterbaseline treatment. Pathological assessment showed no NKA safety-related(macroscopic or microscopic) findings in either the target organ(kidney) or non-target organs examined. No treatment-related kidneyfindings were noted following enhanced evaluation of 8 areas of eachkidney (3 stains per area), including assessment and scoring of 150glomeruli per kidney. All kidneys appeared normal, apart from changesrelated to injection site scars. There were no signs of renalinsufficiency, and no indications of decreased GFR. Detailed informationis provided in the Investigator's Brochure.

Laboratory Assessments

Planned clinical laboratory evaluations are listed in Table 8. Analyseswill be conducted by a central laboratory, except as noted. Thescheduled for collecting biological samples during the study arediscussed above.

TABLE 8 Clinical Laboratory Evaluations Clinical Chemistry HematologyUrinalysis Alkaline phosphatase Hematocrit Albumin ALT Hemoglobinβ2-Microglobulin AST RBC count & indices Creatinine β2-Microglobulin WBCcount & Protein Bilirubin differential Protein & Creatinine kinasePregnancy Albumin:Creatinine FSH (females only) hCG (serum)- Ratio GGTconfirmatory NGAL HbA_(1c) Serology Standard Panel LDH HBV pH PTH(intact) HCV Ketones Renal Analytes HIV Protein Albumin CoagulationStatus Blood BUN APTT Glucose Calcium PT-INR Pregnancy CO₂, totalPlatelet count Microscopic analysis Creatinine Lipid Panel Drug ScreenCystatin-C Cholesterol Amphetamine CRP LDL Barbiturates eGFR(calculated) HDL benzodiazepines Glucose LDL:HDL ratio CocainePhosphorus Triglycerides Opiates Potassium Tetrahydrocannabinol SodiumPhencyclidine Abbreviations: ALT (Alanine Aminotransferase); APTT(Activated Partial Thromboplastin Time); AST (AspartateAminotransferase); BUN (Blood Urea Nitrogen); CRP (C-Reactive Protein);FSH (Follicle-Stimulating Hormone); GGT (gamma-glutamyl transferase);HbA_(1c) (glycosylated hemoglobin); HBV (Hepatitis B Virus); hCG (HumanChorionic Gonadotropin); HCV (Hepatitis C Virus); HDL (High DensityLipoprotein); HIV (Human Immuno-deficiency Virus); LDL (Low DensityLipoprotein); NGAL (Neutrophil Gelatinase-Associated Lipocalin); iPTH(Parathyroid Hormone, intact); PT-INR (Prothrombin Time-InternationalNormalized Ratio).

eGFR

GFR will be estimated using the Chronic Kidney Disease EpidemiologyCollaboration (CKD-EPI) equation that incorporates both serum creatinineand Cystatin C. (Inker et al. Estimating glomerular filtration rate fromserum creatinine and cystatin C. N Engl J Med. 2012; 367:20-9)

Routine Urinalysis

Urine will be collected and analyzed via standard panel. Urine will becollected over two different time periods: 24 hour collection and “spot”urine. Spot urine collections will be used for dipstick urinalysis (teststick) assessments. The schedules for collecting each type of urinesample are shown in To provide a comprehensive picture of protein andalbumin excretion, both total protein and albumin will be assessed inall samples.

Hematology

Hemorrhage following NKA injection is a known and foreseeable risk tosubjects participating in this study. Therefore, hemoglobin andhematocrit will be measured by the sites local laboratory a) before, b)4 hours after, each NKA injection and compared to baseline levels. Otherbleeding parameters (eg, APTT, PTT-INR, platelets) also will bemeasured.

Virus Serology

The biopsy cores obtained from each subject will be used for theexpansion and selection of SRC. Each subject will undergo testing forviral blood-borne pathogens, including HIV, HBV, and HCV.

Drug Screen

Consistent with Exclusion Criterion outlined above, subjects are noteligible to participate in the study if they have an “ . . . activehistory of . . . drug abuse that, in the judgment of the Investigator,would impair the subject's ability to comply with the protocol.”Therefore, subjects will undergo testing for drugs of abuse.

Pregnancy Screen

A qualitative urine pregnancy test will be performed at the site using atest-strip. If the test is positive, then a confirmatory test will beperformed by the clinical laboratory. If site practices do not acceptthe results of a test-strip, then a urine sample should be sent to thecentral laboratory for analysis. Post-menopausal women with aconfirmatory FSH test do not have to undergo pregnancy testingthroughout the study.

Renal Imaging

Ultrasound

Renal ultrasound will be performed at the Screening Visit to verifysubject eligibility (ie, no evidence of renal tumors, polycystic kidneydisease, renal cysts or other anatomic abnormalities that wouldinterfere with the NKA injection procedure) along with obtaining abaseline echogenicity reading. Ultrasound will also be performedfollowing the in-patient renal biopsy on Day 0 and Day 1, and followingthe in-patient NKA injection(s) on Day 0 and Day 1 with the aim ofmonitoring possible, subclinical AEs. Findings from the ultrasound (eg,resistance index, length, etc.) will be recorded on the CRF. Anultrasound may be conducted at other times, in the judgment of theInvestigator, if needed for additional safety evaluation(s).

Computerized Tomography

Computerized tomography (CT) may be used in conjunction with ultrasoundduring the NKA injection procedure, according to the usual standards ofcare at the investigative site.

Magnetic Resonance Imaging

An MRI study without contrast will be performed from the Screening Visitthrough Day −1 before renal biopsy to determine kidney size and volume.During the site initiation visit, the MRI process will be defined foreach site, depending on the MRI equipment available. Generally, a 1.5-Tunit should be used. MRI imaging studies will help determine kidneyvolume (for dosing calculations). MRI will be performed using standardsequences without injection of contrast agents. Renal volumemeasurements may be calculated, for example, using a fast 3Dgradient-echo sequence, VIBE, with an acquisition time of 22 seconds andspatial resolution of 2×1.4×1.2 mm. Imaging parameters will be recordedin the source documents and CRF. A total of four MRIs will be performedon patients.

Renal Scintigraphy

Renal scintigraphy will be used to assess left and right kidney functionusing the radioactive tracer ^(99m)Tc-dimercaptosuccinic acid (DMSA) orTc99m MAG3 (Mercaptoacetyl triglycine). This method is considered as themost reliable for measuring renal cortical function and is the preferredagent for this clinical trial. All patients in this study will receivefour renal scintigraphy studies. Renal scintigraphy will be performedbefore the first NKA injection, before the last NKA injection, at the6-Month Visit after the last NKA injection, and at the EOS Visit for allpatients.

Surgical Procedures

Biopsy

Renal biopsy will be performed under sterile conditions using anultrasound- or CT-guided approach consistent with site practices. Twobiopsy cores will be needed to provide sufficient material for theselection of SRC and manufacture of NKA. Likewise, a 16-gauge needleshould be used to insure adequate cortical material is obtained. Ifrequired, a 15-gauge needle may be used following consultation with theMedical Monitor. Bedside examination of the biopsy cores may beperformed, if available, to ensure sufficient cortical material has beenobtained.

Since the biopsy tissue will be used to manufacture NKA, the site mustensure that the tissue cores are harvested using sterile conditions sothat the risk of contamination during subsequent cell expansion andselection is minimized.

Guidance on wound care and pain management following the biopsyprocedure will be provided in the Study Reference Manual. Briefly, thesubject will remain supine for 4 hours with monitoring of hemoglobin,blood pressure, gross hematuria, abdominal/flank pain, and flankecchymosis. As long as any biopsy-related AEs have resolved, stabilized,or returned to baseline, the subject can be discharged from the hospitalon the day after the biopsy consistent with site standard practice.Importantly, any pain medication administered after the renal biopsyshould be selected carefully, avoiding medications with nephrotoxicpotential.

If a subject experiences significant adverse events following the biopsythat, in the opinion of the Investigator, would put the subject atincreased risk for significant adverse effects following NKA injection,then he/she will not be treated with NKA but will be followed untilresolution of the event(s) and then discontinuation from the study.

NKA Injection

Before performing the NKA injection, the operating physician willevaluate the subject as follows:

-   -   Perform a physical examination to determine the feasibility of        the procedure.    -   Evaluate bleeding parameters, including coagulation panel,        PTT-INR, platelets, hemoglobin, hematocrit, and other pertinent        laboratory studies.        -   Note: Hemorrhage following NKA injection is a known and            foreseeable risk to subjects participating in this study.            Therefore, hemoglobin and hematocrit will be measured a)            before, b) 4 hours after, and c) 24 hours after each NKA            injection and compared to baseline levels.    -   Review imaging studies, including ultrasound, MRI, and/or CT, to        determine route of access, depth of kidney, and appearance of        cortical-medullary junction.    -   Map potential NKA cell deposition sites.    -   Determine classification and associated        perioperative/post-operative risk according to the American        Society of Anesthesiologists (ASA) with respect to airway        assessment, medical history, allergies, and medications.    -   Interview the subject and the subject's family/supporters to        discuss the procedure, its risks and possible complications.        Answer questions, and obtain written informed consent.

Prophylactic antibiotics will be given intravenously according to sitestandard practice. An initial CT scan may be ordered, if necessary, toevaluate adjacent viscera, renal location, and the presence of renalcysts. In conjunction with ultrasound, a CT scan also may help locatethe cortical-medullary junction.

NKA is targeted for injection into the kidney cortex via aneedle/cannula and syringe compatible with cell delivery. The intent isto introduce NKA via penetration of the kidney capsule and deposit NKAinto multiple sites of the kidney cortex. Initially, the kidney capsulewill be pierced using a 15- to 20-gauge trocar/access cannula insertedapproximately 1 cm into the kidney cortex.

In the Phase 1 clinical study, NKA was administered via an 18-gaugeneedle. The proposed Phase 2 study will utilize an 18-gauge or smallerneedle for NKA delivery. The needle will be threaded inside the accesscannula and advanced into the kidney, from which the NKA will beadministered. Injection of the NKA will be at a rate of 1 to 2 ml/min.After each 1 to 2 minute injection, the inner needle will be retractedalong the needle course within the cortex to the second site ofinjection, and so forth, until the needle tip reaches the end of theaccess cannula or until the entire NKA product has been injected. Usinga percutaneous delivery approach, placement of the access cannula/trocarand delivery needle will be performed using direct, real-time imaging.Options include ultrasound alone or ultrasound with complementary CT.

During the procedure, moderate conscious sedation will be employed;vital signs will be measured continuously. NKA injection will cease ifthere is imaging evidence of cell extravasation into central orperipheral renal blood vessels, the medullary portion of the kidney, orthrough the renal cortex and into the retroperitoneal soft tissues, orevidence of active bleeding.

Following completion of the NKA injection, the inner needle will bewithdrawn and the outer cannula will remain in place for trackembolization. During removal of the outer cannula (trocar), the site ofthe renal cortex puncture and needle track through the retroperitoneumwill be embolized with absorbable gelatin particle/pledgets (eg,Gelfoam® [Pfizer]) or fibrin sealant (eg, TISSEEL [Baxter]) or othersuitable agent to prevent excessive renal bleeding.

Upon completion of the procedure, non-contrast CT scan or ultrasoundwith color Doppler evaluation will be performed to image puncture sitecell injection and any hematoma or bleeding events. The subject will bemonitored for 2 to 3 hours post-procedure in a recovery-room environmentwith nursing assessment and measurement of vital signs. Subjects who donot experience complications may be discharged the same day as NKAinjection, consistent with site standard practice.

1. A method for the treatment of chronic kidney disease, the method comprising injecting into the renal cortex of at least one kidney of a patient having said chronic kidney disease a therapeutically effective amount of a composition comprising a bioactive renal cell population (BRC).
 2. The method of claim 1, wherein the injection is performed using a minimally invasive procedure such as percutaneous, laparoscopic, transureteral or intravascular procedures.
 3. The method of claim 1, wherein a guiding cannula inserted percutaneously, intravascularly, or transuretherally is used to puncture the kidney capsule prior to injection of the composition into the kidney of the patient.
 4. The method of claim 1, wherein the composition is administered with a minimum of one injection in one kidney.
 5. The method of claim 1, wherein the composition is administered as two or more injections.
 6. The method of claim 5, wherein the first and second injections are administered at any time up to 3 months apart, any time up to 6 months apart, at annual intervals or at intervals necessary to improve/maintain renal function.
 7. The method of claim 5, wherein the second injections is administered any time up to 3 years after the 1^(st) injection.
 8. The method of claim 5, wherein the first and second injections are administered at least 3 months apart.
 9. The method of claim 1, wherein the composition is administered to subjects who contemporaneously receive standard-of-care treatment for CKD prior to receiving injections of NKA.
 10. The method of claim 1, wherein the composition is injected into one kidney of the patient.
 11. The method of claim 1, wherein the composition is injected into both kidneys of the patient.
 12. The method of claim 1, wherein single or multiple entry points are used to inject the composition into the kidney of the patient.
 13. The method of claim 1, wherein the injection is into the renal parenchyma.
 14. The method of claim 1, wherein the patient receives a therapeutic dose at any given injection site.
 15. The method of claim 14, wherein the patient receives a dose of 1-9×10⁶ SRC/g KW^(est) at any given injection site.
 16. The method of claim 1, wherein the patient's chronic kidney disease is defined by an estimated glomerular filtration rate (eGFR) in the range of 15 to 60 mL/min.
 17. (canceled)
 18. The method of claim 1, wherein the patient's kidney function is improved as a result of the treatment.
 19. The method of claim 18, wherein the improved kidney function is demonstrated by a reduction in the rate of decline or increase in estimated glomerular filtration rate (eGFR).
 20. The method of claim 18, wherein the improved kidney function is demonstrated by reduction in total serum creatinine or the rate of increase in serum creatine (sCr).
 21. The method of claim 18, wherein the improved kidney function is demonstrated by improved renal cortical thickness.
 22. The method of claim 18, wherein the improved kidney function is demonstrated by reduced fibrosis, increased blood flow, reduced inflammation, or reduced urinary albumin/protein.
 23. The method of claim 18, wherein the improved kidney function is demonstrated by improvement in one or more of the factors in Table
 5. 24. The method claim 18, wherein the improved kidney size and/or structure is determined by renal imaging.
 25. The method of claim 24, wherein the method of renal imaging is selected from ultrasound, MRI, renal scintigraphy, biopsy or other medical diagnostic method.
 26. The method of claim 18, wherein the improved renal function is superior to the prior state of the kidney.
 27. The method of claim 1, wherein the bioactive renal cell population is a selected renal cell (SRC) population obtained after density gradient separation of the expanded renal cells.
 28. The method of claim 1 or 27, wherein the BRC or SRC contains a greater percentage of one or more cell populations and lacks or is deficient in one or more other cell populations, as compared to a starting kidney cell population.
 29. The method of claim 31, wherein the kidney biopsy sample is derived from a native autologous or allogeneic kidney sample.
 30. The method of claim 31, wherein the kidney biopsy sample is a non-autologous kidney sample.
 31. The method of claim 1 or 27, wherein the BRC or SRC is obtained from a kidney biopsy sample.
 32. The method of claim 1 or 27, wherein the BRC or SRC is formulated in a biomaterial.
 33. The method of claim 32, wherein the biomaterial comprises a gelatin-based hydrogel. 